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Interconception Care Program Recruitment Strategies

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Interconception Care Program Recruitment and

Retention Strategies

October 24, 2012

Today’s Webinar

Why This Topic?

Reducing risks indicated by a previous adverse pregnancy outcome is a top goal of the National Preconception Health and Health Care Initiative

In the SE – 3 states have demonstration projects to provide interconception care to high risk women

Limited information about best practices in serving this population

Objectives

Describe current efforts to promote interconception health care for high risk women

Describe how to overcome at least one challenge to recruitment

Describe at least two strategies that improved recruitment and retention

Discuss ways that interested groups can continue to connect on this issue.

Speakers

Sarah Verbiest, DrPH, MSW, MPHDean Coonrod, MD, MPHJennifer Culhane, PhD, MPHAnne Dunlop, MD, MPHBetsy Bledsoe-Mansori, PhD, Mphil, MSWCarol Brady, MPH

S a r a h Ve r b i e s t , D r P H , M S W, M P H

E x e c u t i v e D i r e c t o r

U N C C e n t e r f o r M a t e r n a l a n d I n f a n t H e a l t h

D i r e c t o r

E v e r y Wo m a n S o u t h e a s t C o a l i t i o n

The Postpartum Plus Prevention Program in NC

The Postpartum Plus Prevention Program (P4)

Designed to increase knowledge about how to provide health and wellness services to mothers of medically fragile infants.

Services: postpartum visit, a wellness kit at 3 months, and contact with a nurse midwife at 3, 6, 9, 12 and 18 months postpartum.

P4 also provided onsite medical care to any woman in the NICU who requested help.

Enrollment

Women were approached for enrollment by a nurse midwife while their infant was in the NICU. We didn’t have anyone decline participation.

A convenience sample of 44 mothers was recruited from the Newborn Intensive Care Unit at UNC.

Nearly all (87%) of the women had received a medical service from the nurse midwife prior to being recruited into the study.

What We Found

Almost every mother (97%) returned to UNC post-discharge for infant follow-up.

Initial expectations were that mothers would only be reachable by phone but the majority of mothers also received in-person support.

Mothers were open to talking with the nurse midwife during pediatric visits for their infant.

Contacts

We anticipated about 220 total contacts with the women in the study. We had 645 contacts!

The nurse midwife had an average of 15 contacts with each mother. The number of contacts per woman ranged from 6 to 42 – the lowest number was still above our expectation.

One third of the women went through a period of time where they had weekly contact with the nurse midwife – usually due to a crisis in their baby’s health.

Content

Almost all contacts began with a mother-led conversation about the infant’s health.

The nurse midwife introduced wellness messages in the context of the impact of the mother’s health on the well-being of her infant.

Mothers needed support for nonmedical issues such as relationship with the infant’s father, poverty, employment, and loss/grieving.

Conclusions

Mothers of medically fragile infants are receptive to tailored wellness messages when provided along with clinical care for themselves and their baby.

The NICU provides a key opportunity for initial outreach to high-risk mothers.

Telephonic support is a good option for providing services and support, especially when paired with in-person contact through pediatric services to the infant.

Conclusions

Mothers’ capacity to attend to their own health and wellness needs is linked to the immediate health status of their infant.

Easy access to health care services from a professional they trusted was very important.

Innovative partnerships between OB/GYN and NICU follow-up clinics should be considered to best serve both high-risk mothers and infants.

ARIZONA’S INTERNATAL CLINIC

Dean V Coonrod, MD-MPHChair, Department of Ob/GynMaricopa Integrated Health System / District Medical GroupUniversity of Arizona College of Medicine - Phoenix

Context

Preconception vs Interconception vs Internatal Care

= preconception care

= pregnancy

= no more kids!

= internatal care

* *

* = interconception

Program Eligibility

Index pregnancy Preterm birth 35 weeks or less Early pregnancy loss 15 weeks and more Stillbirth Low birthweight Prolonged NICU stay

Initially 3 days now 5 days Not permanently sterilized

Schedule of Visits

2 weeks Breastfeeding, review family planning

6 weeks Standard postpartum visit

6 months 12 months Yearly thereafter Preconception visit

Our Visits

Seen by care coordinator Introduce program Edinburg Postpartum Depression scale “6-week” intake form Go over education & goals for nutrition,

exercise, dental care, folate Psychosocial support, stress management

Our Visits

Seen by physician Reason for visit Index pregnancy reviewed Neonatal status

Breast feeding / back to sleep Prior ob history Reproductive life plan, contraception Gyn, STI history / screening PMH / PSH / Dental care

Underlined = Done at all visits

Our Visits

Infection / immunization

TB, Rubella, Tdap (pertusis), varicela, influenza

Nutrition / exercise

Anemia, food security, BMI, folate, exercise (type / amount)

Meds / allergies

Habits / Social / Exposures

Tobacco, alcohol, drugs, DV, work, environmental exposures

Behavioral health

EPDS, other mental health, eating disorders

Physical exam

Weight (BMI), BP etc

Problem focused exam

Our Project Patients: End of 2010 696 approached 142 had a visit

90% Latina71 seen for clinical services in the last 6

months and are considered active 71 have relocated or have been lost to

follow up

Final Results (n=102 women)

In program for 12 to 18 months Of those pregnant at least 12 month interval Of those pregnant with first trimester care Of those pregnant, tob, ETOH, drug free Using contraception (if indicated) On folate Regular exercise (30 min 5 days a week) Normal BMI Those with oral health needs who have

treatment Those with mental health needs who have

treatment

64%

40%

87%

100%

88%

61%

23%

26%

20%

100%

Follow Up Data

Baseline 6-month 12-month

Health is Excellent 46% 55% 70%

Regular Exercise 23% 76% 70%

Very Interested in Getting Preconception Information

53% 76% 69%

Alcohol Can Effect Fetus 73% 83% 94%

Watchful About Eating Fish 48% 77% 88%

Lessons Learned

Care coordination key Mothers / families after a pregnancy ending in

stillbirth very interested Patients with preterm birth have varying levels of

interest No show rate a significant problem Interval of visits often dictated by family planning

or other issues / mental health Usually more frequent than the idealized one

TLC is always provided and likely of benefit

Thanks to our partners and funders: March of Dimes Maricopa Dept of

Public Health ADHS

BHS Mercy Care Plan University Health Plan Az Public Health

Association Mayo Clinic Family

Medicine

Maricopa Integrated Health System Ob/Gyn MFM Family Medicine Ambulatory Social Work

Southwest Human Development

St Luke’s Health Initiatives

AHCCCS

Questions?

Dean_Coonrod@DMGAZ.org

The Philadelphia Collaborative

Preterm Prevention Project

Jennifer F. Culhane MPH, PhD

The Study Before discharge from the post partum hospital

stay– Consent including access to medical records– Conduct survey– Randomization – Smoking intervention begins– Schedule 1st postpartum visit (1 month)

Postpartum Study Visits

When: 1, 6, 12, 18, and 24 months postpartum

Or, at 20 weeks gestation of the subsequent pregnancy

Postpartum Study Visits Survey Periodontal exam (1, 12 and 24

months only) Vaginal fluid (self collection) Blood Urine Anthropometric measurements Blood pressure Transportation, flexible hours,

childcare, barriers eliminated

Intervention Arm

Evaluated and offered treatment for:– Depression– Periodontal disease– Urogenital tract infections– Abnormal BMI– Housing instability/inadequacy– Smoking– Literacy

Figure 2. Webb, et al. BMC Medical Research Methodology, 2010, 10:88

Recruitment Rate

77.7%

Randomization

Intervention

Group Control Total

First Post PartumAssessment

83.5% 76.0% 80.0%

Second Post PartumAssessment

67.6 57.5 64.6

Third Post PartumAssessment

60.0 48.9 54.4

Fourth Post PartumAssessment

54.2 46.3 50.3

Fifth Post PartumAssessment

47.3 40.8 43.6

Retention/Data Capture Rates for Study Population

Strategies to Improve Retentions• Two full-time staff dedicated to cohort

maintenance • Provided transportation - either tokens or cab

pick up• Evening and weekend hours• Child care and food provided

• If required visit conducted at participant's home

• Clinic had washing machines and dryers• Staff required to be courteous and totally

participant -focused• Compensation for time

Prevalence/ Acceptance Particpation Eligible (a) Rate (b) Rate 2

N (%) N (%) N (%) Intervention/ Treatment Infection 268 (57.1) 240 (87.9) 228 (85.1)

Periodontal 265 (59.4) 233 (87.9) 136 (58.3)

Smoking 185 (38.9) 99 (53.8) 53 (28.6)

Depression 1 290 (61.1) 223 (76.9) 140 (48.3)

Literacy 105 (22.1) 79 (75.2) 62 (59.0)

Housing 389 (81.9) 356 (91.5) 319 (83.3)

1 Depressive Symptomatology (CESD > 16) 2 Percentages are based on the number of women eligible in column 1

Risk Factor Prevalence, Acceptance Rates and Rates of Minimal

Participation in PCPP Intervention Arms

Strategies to Improve Participation in Interventions

• Phone medicine for depression care available• Staff accompany participants to dentist

• Provide valium for dental visits• Smoking intervention conducted in

particpant’s home• Medicines delivered to particpant’s home• Food and caloric supplements delivered to

participant's home

Selected Findings Exposures associated with adverse outcomes are moderately prevalent and co-occur.

There is a wide range of participation across interventions- even with every traditional barrier to care addressed.

Volunteering for treatment is MUCH different than random assignment to treatment- people who really need the intervention may not seek care

Important Research Questions Why don’t some women avail themselves of care?

Not just traditional barriers to care

Complex decision making that may seem irrational to providers but may make perfect sense in certain contexts- what are those contexts?

Important Research Questions RHIME factors (Racism, Housing challenges, Insufficient resources, Multiple burdens and Emergencies) play a role in women’s everyday lives and influence care participation

We need to become aware of, document and address the ways various institutional structures, rules and ways of doing business create additional burdens for already stressed women

Summary

Truly ‘at risk’ women may not participate

Even if an intervention “works” it may not be successfully implemented- what do we mean by works?

More research needed to understand complex barriers to participation

The Interpregnancy Care Program

Overview of Engagement Strategy For Women Who Recently Delivered

A Very-Low-Birthweight Infant

Anne L. Dunlop, MD, MPHOctober 24, 2012

IPC Participants

Eligibility: African-American women who qualified for indigent care and delivered a VLBW infant at Grady Memorial Hospital (GMH) during

the feasibility phase (11/2003 through 3/2004). Recruitment/Enrollment:

29 women enrolled (of 38 eligible); 24-months of follow-up complete 3/2006.

IPC Intervention Package Definition of an individualized IPC plan to address 7 areas

epidemiologically linked to low birth weight/preterm delivery: Reproductive planning (assistance in achieving intendedness and spacing) Prevention, screening and treatment for sexually-transmitted infections Micronutrient supplementation & screening/treatment for nutritional

deficiencies Prevention, screening and treatment for periodontal disease Management of chronic disease Treatment and referral for substance abuse Screening and treatment for depression, psychosocial stressors, &

domestic violence Provision of health and dental services in accordance with the

IPC plan for 24 months; Community outreach via a trained Resource Mother.

Provision of IPC Contact with a multidisciplinary team:

Family nurse practitioner, family physician, periodontist, nurse case manager, social worker, and Resource Mother;

Initial contact with nurse case manager followed by Resource Mother during the delivery hospitalization.

Primary care visits occurred every 1 -3 months (dependent upon extent of health problems) in a group setting with integration of group educational experiences according to the Centering Pregnancy Model of prenatal care;

Home visits and telephone contact by the Resource Mother monthly to address psychosocial issues.

Participation in IPC 21/29 (72%) actively participated;

8/29 (28%) not actively participated: 2 moved out of state; 3 electively disenrolled (2 prior to 1st IPC visit; 1 after

single visit); 3 become lost to follow-up (2 prior to 1st IPC visit; 1 after

single visit).

Impact of IPC: Social Outcomes (Education)

Educational Attainment:

18/21 (85.7%) active participants without h.s diploma or GED at study entry;

Of those 18 without diploma or GED, 13/18 (72.2%) were assisted in earning diploma or GED during the study: 8/18 earned h.s. diploma or GED;

5/18 enrolled in G.E.D. training program, but did not complete the program.

Impact of IPC: Social Outcomes (Training)

Other Training:

In addition to GED, 4 participants completed technical training (2 computer literacy, 2 medical assistance);

In addition to h.s. diploma, 1 participant completed Upward Bounds (college preparatory program);

A participant with a h.s. diploma completed technical training (administrative assistance).

Impact of IPC: Social Outcomes (Housing)

Housing Acquisition:

14/21 active participants with inadequate (crowded, dirty, unsafe) housing or homeless at study entry;

Of those 14 who were homeless or with inadequate housing, 11/14 assisted in finding adequate housing.

Cost of IPC per Participant: Full 24 months

Health care: Mean charges = $ 2,397 (median = $2,104)

Mean visits = 7 (median = 6) Mean cost per visit = $342 (median = $350)

Resource mother outreach:

Estimated $1,800

Total Program Cost per Participant per 24-Months: $4,197

Cost Analysis The 29 enrolled women received 24-months of IPC at

$4,197 each, and delivered 1 LBW infant (initial hospitalization $55,576) conceived within 18-months of the index VLBW: Cost of program: 29 x $4,197 = $ 121,713 Cost of LBW infant: $ 55,576

$ 177,289 Based on the historical control cohort, we expected 5 LBW

infants to be conceived within 18-months of the index VLBW: Cost of LBW infants: 5 x $55,576 = $277,880

Net savings: $100,591

Translation of IPC: “Planning for Healthy Babies” Georgia Medicaid Waiver,

beginning January 2011, will expand Medicaid coverage for specific reproductive health services to Georgia women ≤ 200% FPL:

Family planning services (broadly) for all women of reproductive age; ‘Interconception primary care, case management, and resource

mother support’ for all women who deliver a VLBW infant after Jan 1, 2011.

Services to be delivered through the Georgia Medicaid CMO’s:

Amerigroup, Peach State, WellCare

Small trial of NICU-based engagement in 3 metro area NICUs

Engaging and Retaining Difficult to Reach Mothers

in Treatment Services: Overview of a Brief Intervention.

Betsy (Sarah E.) Bledsoe-Mansori, PhD, MPhil, MSW

Assistant Professor – School of Social WorkUniversity of North Carolina at Chapel Hill

October 24, 2012

Acknowledgements

Pregnant women and adolescents from Pittsburgh, PA; Seattle and King County, WA; and Alamance and Wake Counties, NC who participated in the research studies supporting this work.

Funding sources -- National Institute of Mental Health, National Institutes of Health, Horizons Foundation, Seattle, WA, Jane H. Pfouts Research Grant, Armfield-Reeves Innovation Fund, University of North Carolina Program on Ethnicity Culture and Health Outcomes, University of North Carolina

Co-investigator s and collaborators: Nancy Grote, PhD; Holly Swartz, MD; Allan Zuckoff, PhD; Ellen Frank, PhD; Katherine Wisner, MD; Wayne Katon, MD; Carol Anderson, PhD; Sharon Geibel, MSW

Distal Influences ----> Proximal Influences ----> Rx Adherence ----> Rx Outcomes 

Community Barriers Helping System Barriersviolence, safety concerns bias or cultural insensitivity in lack of support services environment, procedures, providersunemployment; poverty lack of evidence-based treatmentslack of access to M.H. services lack of diversity in clients & staff provider overload and burn-out

Social Network Barriers Client Barriers negative attitudes toward RX practical- time, financial, transportation, childcare

social network strain psychological - stigma, low energy,

negative RX experiences; previous or current trauma cultural – women’s view of depression; multiple stressors culture of poverty; culture of race/ethnicity/nationality

 

An Ecological Model of Barriers to Treatment Engagement and Retention

Barriers to Care

Practical – Do I have time? Can I get there? Can I afford it?

Psychological – Can I trust my therapist? Can she/he really understand me and help me?

Cultural – Will treatment be relevant to my needs, goals, values, preferences and practices?

Practical Barriers to Care

Costs◦ 40% African Americans and 52% Hispanics lack

health insurance in the US (US Census Bureau, 2003)

Access• Inconvenient or inaccessible clinic locations• Limited clinic hours• Transportation problems

Competing Obligations• Child care and social network• Loss of pay for missing work• Time in dealing with chronic stressors

Psychological Barriers to Care: STIGMA: “I don’t want to be that person to get the

medication and be called “DEPRESSED”; my sister had to live with that label – and everyone avoided her and treated her like it was her fault.”

NEGATIVE EXPERIENCES WITH SERVICE PROVIDERS:

“I didn’t want the therapist to report my depression to child protective services because they might take my baby away. I felt betrayed.”

CHILDHOOD TRAUMA AND LACK OF TRUSTGreater risk of insecure attachment and lack of

trusting others (Mickelson et al., 1997)

Implications for seeking treatment: go-it-alone attitude; poor collaboration, missed appointments; requires extensive outreach

Cultural Barriers to Care:

CULTURE OF POVERTY“My therapist seemed overwhelmed by all my

practical problems, so how could she help me?”

CULTURE OF RACE/ETHNICITY/NATIONALITY

No – it doesn’t matter… “Sitting in front of a white therapist isn’t

necessarily like she thinks she is better than me, BUT there are some white people who think they can look down on you and show favoritism to people of their nature and culture and treat you any kind of way.”

Development of an Engagement StrategyBefore Treatment Begins

To deal with practical, psychological, and cultural barriers to care and ambivalence about going for depression treatment

Integration of two theoretical approaches:

◦ Ethnographic interviewing

◦ Motivational interviewing

Ethnographic Interviewing (EI)

A method of eliciting information designed to help the interviewer understand the ideas, values, and patterns of behavior of members of another culture without bias (Schensul, Schensul, & LeCompte, 1999)

◦Anthropological Uses

Foreign cultures

Sub-cultures

-

Motivational Interviewing (MI)

Client-centered, goal-oriented method for enhancing a person’s own motivation to change by working with and resolving ambivalence (Miller & Rollnick, 2002)

Principles of Engagement (Grote, Zuckoff, Swartz, Bledsoe, & Geibel, 2007)

1) Work to understand the perspectives and values of the woman without bias or agenda

2) Adopt a one-down position as learner

3) Help the woman to feel safe to tell her story (what’s bothering her) without fear of judgment

4) Find out how the depression or stress is interfering with what is important to her – this primary motivator for change!

Principles of Engagement

5) Affirm the woman’s strengths and coping capacities (e.g., resilience, knowledge, spirituality, family)

6) Obtain permission before giving information or advice

7) Provide psychoeducation about the problem and effective treatments and elicit the woman’s reaction

8) Identify pros and cons about getting treatment (ambivalence); pull for the negatives

9) Express empathy, especially for the reasons against seeking treatment (as well as reasons for seeking treatment)

Principles of Engagement

10) Foster personal choice and control ( “It’s up to you!”)

11) Problem-solve all the barriers with the woman

12) If the woman commits, collaborate with him or her to make the connection with mental health services

13) Offer hope, acceptance of ambivalence, affirmation

14) Leave the door open, if she does not commit

Engagement Session: 5 components(Unpublished manual, Zuckoff, Swartz, Grote, Bledsoe & Speilvogle)

Total time: 50-60 minutes -- These components can be used separately if time is limited or repeated as needed.

1) Getting the story

2) Past efforts at coping and attitudes toward treatment

3) Feedback and psychoeducation

4) Addressing barriers to care

5) Eliciting commitment and planning for treatment engagement

Engagement Component 1: The Story Introduce session

◦ “During this time I would like to get to know you better – how you see what’s bothering you, whether you want help, and if so, what you would want out of treatment services.”

◦ “How have you been feeling lately and how is this interfering with what’s important to you?”

Explore the Story

A. Problem: understanding of the woman’s view of her depression/stress & how it is interfering with client’s life

B. Context: social context of the problem: acute stressors (stressful life events; pregnancy) and chronic stressors (like poverty)

C. Summary: empathically summarize client’s story; highlight concerns and wishes; identify and affirm strengths

Engagement Component 2:Treatment History & Hopes for Treatment

History of the problem: ask about past or current efforts to cope with the problem (e.g. spiritual beliefs, family, inspirational people); identify and affirm strengths – empathically summarize

Treatment history: ask about client’s or family members’ experiences with or ideas about treatment; get both positive and negative; ask about experiences with social agencies/health care providers

Treatment hopes/expectations: ◦ “What would you like to be doing if treatment worked?”◦ “What do you want/not want in treatment or in a

therapist?” Does race/ethnicity matter?

◦ Empathically summarize hopes and fears for treatment, capturing the woman’s ambivalence while highlighting hope

Engagement Session Component 3:Feedback and Psychoeducation Feedback

A. Elicit: “Would it be OK if I shared some of the results from the questionnaire you filled out?” or “my ideas about what you’re struggling with?”B. Provide: symptom severity, consequences of depression/stressC. Elicit: “What do you make of this?” “How does this sound?”

PsychoeducationA. Elicit: “What is your view of depression?” “Would it be OK if I gave you some information about it and treatment options?”B. Provide: information about depression and treatmentC. Elicit: “How does this sound to you?” “Does this make sense?”

Engagement Session Component 4:Problem-solving the Barriers to Care Practical – “What might make it hard to come even if you

wanted to?” Transportation? Childcare? Scheduling? Finances?

Psychological – “Beyond these practical concerns, what else might keep you from coming?” Keep asking, “What else”?

Negative attitudes about treatment? The burden of dealing with the symptoms of the problem? Guilt about taking time for self? Concerns that CPS might become involved? Doubts about whether treatment will help? Perceived stigma from family and friends?

Cultural – “How is treatment viewed in your family or community?” 1) How can treatment help me with getting a job, house, food, etc.?2) Preferred community approaches for treatment (e.g., church)?3) Therapist differences in race, class, gender, age, nationality?◦ therapist would judge, not understand, act disrespectful, not

care◦ therapist does not know how to cope with client’s

problems – no experience

Engagement Session Component 5: Elicit Commitment

Grand Summary: summarize woman’s story, ambivalence, barriers and solutions; highlight her change talk – “I can’t take this anymore.”

Change Plan: outline next steps, e.g., scheduling an appointment, number of treatment sessions

Elicit Commitment: “What would you like to do?” “Does this sound right for you?

Leave Door Open: “It’s fine if you want to think about it, you can give me a call.”

Instill Hope: Affirm woman’s participation in the session and the strengths client brings to treatment; express optimism about treatment

Randomized Study of Pregnant, Depressed Women:

Rx Engagement and Retention (Grote, Zuckoff, et al., 2007)

00.10.20.30.40.50.60.70.80.9

1

1stsession

4 plus 7 to 8

No Engagement

Engagement

Less than 1/3 of phone intakes attend 1 Rx session in community mental settingsTypical number of Rx sessions attended in community mental health = 1

p<.001 p<.001 p<.001

% with Major Depression Diagnoses

00.10.20.30.40.50.60.70.80.9

1

Pre-Rx Post-Rx Follow Up

Brief IPT

Usual Care

Pre – Post-Rx: p<.05 Pre – F/U: p<.05

92%

79%

5%

42%

0%

30%

Feasibility Study of Depressed Pregnant Adolescents (Bledsoe, Wike, Olarte, et al, 2010)

88% of eligible adolescents entered and 93% completed.

More Research on Engagement Session“PREMIUM” (Program for Effective Mental

Health Interventions in Under-resourced Health Systems) in Goa, India funded by the Wellcome Trust, UK (Vikram Patel, PI)

“Patient Navigation for Depressed Mothers in Head Start in Boston, MA- An Engagement Strategy funded by NIMH (Michael Silverstein, PI)

Facilitated by:

Amy Mullenix

Every Woman Southeast co-chair

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