A Review

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A Review Synthesis of the Interconception Care
Components of 35 Healthy Start Grantees

• Presentation by Kay Johnson
• National Healthy Start Grantee Meeting
• August 7, 2007
• This work is supported by the Maternal and Child
  Health Bureau, Health Resources and Services
  Administration.

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Life Course Perspective
White
Primary Care for Children
Early Intervention
African American
Prenatal Care
Prenatal Care
Primary Care for Women
Interconception Care
Adverse Birth Outcomes
0
5
Age
Pregnancy
Puberty
Source Michael Lu, 2003
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Why interconception care should be easy

• Most of the women in need of interconception
  care are already known to the medical care system
• Over 95 had prenatal care and gave birth at
  hospital
• All live births and still births identified by
  certificates
• Most miscarriages or elective abortions were
  cared for in the medical care system
• Most take infant to pediatric care provider
• Many seek family planning services
• Why interconception care is hard
• Consumer demand and provider supply are low
• Models of care are poorly developed

Adapted from Klerman, National Summit on
Preconception Care, June 2005
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Interconception Care in Healthy Start

• Since 1992, Healthy Start grantees have used
  various approaches to reduce infant mortality and
  morbidity.
• In recognition of its role in eliminating
  disparities and improving maternal and infant
  outcomes, interconception care has been one of
  the nine core components of Healthy Start since
  2001.

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35 Selected Healthy Start Grantees

• 35 grantees have had interconception care
  components since 2001
• 6 with special funding
• 29 with grants of more than 1 million
• Special funding and focus on these 35 sites
  ended in 2005

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Why study these 35 grantees?

• Work in these 35 communities varied in approach,
  intervention scope, community engagement, and
  intensity.
• Together, it forms the largest set of efforts
  aimed at using interconception care to improve
  the health of high-risk women, their infants, and
  their families.

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High Risk Women

• High-risk here refers to pregnant or postpartum
  women who are identified as at increased risk for
  a maternal complication including, but not
  limited to
• low birth weight,
• short gestations,
• preexisting maternal medical problem,
• fetal loss, or
• neonatal death.

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2001 Guidance on Activities

• Examples of Areas for Risk Assessment/Screening
• Individual and social conditions (age, diet,
  education, housing, and economic status).
• Adverse health behaviors (tobacco, alcohol,
  illicit drug use).
• Examples of Health Promotion Strategies
• Promotion of healthy behaviors (e.g., proper
  nutrition, avoidance of smoking, alcohol,
  teratogens, and practice of "safe sex').
• Counseling about the availability of social,
  financial and vocational assistance programs.
• Examples of Intervention Strategies
• Linkage to appropriate treatment of medical
  conditions, including changes in medications, if
  appropriate, and referral to other high-risk
  programs.
• Primary care for mothers and infants throughout
  the interconception care period.

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2005 Guidance on Activities

• all healthy Start programs must demonstrate
  that the program's core and high risk
  interconceptional activities include the
  following
• Knowledge, throughout the community, of what
  interconceptional care is, and what the related
  health outcomes are
• An understanding of the gaps that exist in
  providing interconceptional care services and
• A record of completed referrals for both
  inter-conceptional and specialty health care
  services for those women who are identified as
  needing these services

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Purpose of this Study

• To review systematically and synthesize the
  interconception care goals, methods, activities,
  and results from 35 select Healthy Start grantees
• Not an evaluation
• Looking for lessons learned

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Methods

• Review by Johnson of 35 grantees impact reports,
  data, and other evaluations
• Narrative review using qualitative research
  methods such as NVivo
• Compilation and review of data submitted to MCHB
• Subset of 10 sites also reviewed by other experts
• Vet findings with grantees
• Report on
• Lessons learned to inform future
• Promising practices for replication
• Opportunities to refine Health Start
  interconception activities

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Acknowledgements

• Carol Brady
• Karla Damus
• Amy Fine
• Vijaya Hogan
• Milt Kotelchuck
• Lorraine Klerman

• Michael Lu
• Pat McManus
• Magda Peck
• Carolina Reyes
• Margo Rosenbach
• Kimberly Wyche- Etheridge

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Key Findings Limited Resources

• With limited resources and high levels of need,
  it was difficult for grantees to make sufficient
  effort and achieve interconception goals.
• Lack of health coverage for women
• Shortage of providers (eg, mental health)
• Limited funding for case management

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Key Findings Women Participants

• Targeted groups of higher risk women and infants.
• Focused interconception care on women who had
  been prenatal program participants.
• One-third did not give priority to other
  high-risk women for interconception care.

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Key Findings Infant Health Focus

• Tendency to focus on infant health and
  development, more than womens health.
• May be due to
• current nationwide interest in early childhood
  development,
• continuing health coverage for the child,
• more well-defined measures for child health,
  and/or
• families being more likely to accept assistance
  for their childs needs moms more focused on
  baby.

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Key Findings Case Management (1)

• All used care coordination and case management as
  the primary approach to improving interconception
  health.
• Primarily through individual home visits.
• Some through center-based efforts.
• A few using group care methods.

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We have found that two aspects of our
interconception approach work well. First,
personal, compassionate and consistent contact
provided over time by staff builds trust and
confidence. Second, the flexibility of the
program to address concerns in an individualized
way that is uniquely tailored to a particular
client and family provides confidence that health
and psychosocial needs can be satisfactorily
met. Maajtaag Mnobmaadzid Healthy Start,
Intertribal Council, Michigan
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Key Findings Case Management (2)

• Devised tiered levels of care coordination and
  case management, using
• community-based lay health workers and
• professionals (nurses, social workers, etc.).
• Promising practices that should be considered by
  other community and state perinatal care
  coordination / case management projects.

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(No Transcript)
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Key Findings Direct Services (1)

• 54 (19 of 35 grantees) provided data tracking
  program participant use of direct care services
  in two or more years of the 5-year study period.

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Key Findings Direct Services (2)

• Of the 19 sites reporting direct service data for
  two or more years during study period
• 12 reported on postpartum visits
• 14 reported on family planning services
• 10 reported on womens health services

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Key Findings Direct Services (3)

• Success in assuring direct care services was
  associated with linkages to primary care clinics.
• Community health centers / federally qualified
  health centers (FQHC)
• Hospital outpatient clinics
• Health departments with primary care

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Key Findings Direct Services (4)

• Tens of thousands of high-risk, low-income women
  were screened for risks and adverse health
  conditions.
• Consistent with ACOG CDC recommendations.
• Inconsistent data reporting makes it difficult to
  interpret or compare effort.

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Screening Intervening by Condition
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Sample 1. Risk Reduction/Prevention Services
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Sample 2. Risk Reduction/Prevention Services
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Key Findings Tools (1)

• Risk assessment tools, staff training methods,
  health education curricula, home visiting
  protocols, etc. were developed.
• Little evidence that these have been validated or
  standardized.
• Much could be gained by encouraging use of more
  standardized tools, curricula, and protocols,
  based on what has been designed by these grantees.

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Key Findings Tools (2)

• Depression screening is another component of
  Healthy Start.
• Depression screening and follow-up are important
  services in interconception care component.
• Most grantees are using standardized screening
  tools and facilitating referrals.

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Key Findings Tools (3)

• Healthy Start grantees are using perinatal data
  tools to inform interconception care.
• Perinatal Periods of Risk (PPOR)
• Fetal-Infant Mortality Review (FIMR)
• These data tools should be more widely used at
  the local level, particularly in areas with
  concentrations of high-risk women and infants.

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Key Findings Systems Issues (1)

• Few sites focused their interconception care
  efforts on community-wide barriers or applied
  ecological models used in prenatal care
  components.
• Few grantees are focused on the systemic
  barriers related to interconception care through
  their Local Health Systems Action Plan.

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Key Findings Systems Issues (2)

• Many low-income women lose Medicaid 60-days
  postpartum and become uninsured
• Most commonly cited barrier to assuring
  interconception care.
• Short of Medicaid expansions, more attention
  could be given to maximizing these two months of
  coverage.
• i.e., helping women complete postpartum visits,
  fill contraceptive prescriptions, or visit a
  professional for counseling within 60 days

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Medicaid Family Planning Waivers
As of October 2004
Implemented FP waiver No FP waiver Healthy Start
Interconception Grantee
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Key Findings Systems Issues (3)

• Many low-income women need mental health services
  for depression
• A commonly cited challenge.
• Opportunities to use and improve safety net
  provider services.
• Community health centers/FQHC
• Community mental health centers
• Specially funded perinatal depression efforts

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Key Findings Impact (1)

• Many grantees met or exceeded their objectives
  for interconception care.
• But, reported results are difficult to compare
  and aggregate.
• Different definitions for measures.
• Poorly defined denominators.
• Different counts for participants.

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Key Findings Impact (2)

• Misaligned measures different definitions
• Example Ongoing primary care
• one visit during 12-month postpartum period, vs.
• having a routine source of care identified.
• Example receiving family planning services
• receiving FP counseling from a case manager,
• having initiated a contraceptive method, or
• completing a postpartum family planning visit.

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In getting from Point A (2001) to Point B (2005)
lessons were learned

• Defining what we mean by interconception care
  and services is essential.
• The hardest to reach women are even harder to
  reach after they give birth. We dont know for
  certain what works, but have promising practices.
• Time and effort is being wasted by creating new
  tools and measures for each community.
• Setting realistic objectives, and counting well
  what we do, is fundamental.

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Recommendations to Improve Preconception Health
and Health Care

• Individual responsibility
• across the life span
• Consumer awareness
• Preventive visits
• Interventions for identified risks
• Interconception care
• Pre-pregnancy check ups
• Coverage for low-income women
• Public health programs strategies
• Research
• Monitoring improvements

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At the 2nd National Summit on Preconception
Health and Health Care, more than 8 grantees will
present and national overviews of Healthy Start
work will be presented.
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Interconception care offers an important
opportunity to further improve health outcomes
for high-risk women and their infants. Healthy
Start leaders know why. Healthy Start leaders
know how. You need to tell the story.