Slide 1 Addressing Disparities in Perinatal Health Using a Collaborative Approach: The PCC Community Wellness Center’s Experience May 17th, 2006 Mark Loafman, MD, MPH Andrea McGlynn, CNM, MSN Chicago, Illinois Slide 2 PCC Highest Areas of Patient Population A map is labeled Chicago Community Areas and Zip Codes. An outlined portion of the map includes parts of Areas 25, Austin; 19, Belmont Craqin; 23, Humboldt Park; 20, Hermosa; and 22, Logan Square. This area includes the zip codes 6 0 6 3 9, 6 0 6 4 4, and 6 0 6 5 1. Also within this area are numbers of a different color: 8 2 8 2, 8 6 1 3, and 5 9 8 5. Finally, the area includes letter-number combinations A2, A3, A4, A5, A6, A9, A10, B1, and C1. Slide 3 Austin Community Selected Demographic slash Health Data, asterisk On a bar graph, the X-axis lists races and the Y-axis shows percentages of the population. The bars labeled Austin indicate 0.6 percent Asian, 89.7 percent Black, 4.1 percent Hispanic, 4.8 percent White, 0.7 percent multiracial, and 0.1 percent other. The bars labeled Chicago indicate 4.3 percent Asian, 36.4 percent Black, 26 percent Hispanic, 31.3 percent White, 1.6 percent multiracial, and 0.3 percent other. Asterisk: Chicago Department of Public Health, Chicago Health and Health Systems Project, April 2006 2000 Census Data Slide 4 Austin versus Chicago Infant Mortality 2003 On a bar graph, the X-axis lists Austin and Chicago and the Y-axis shows rates per 1,000 live births. Austin’s rate is 15.8, and Chicago’s is 9.6. Austin versus Chicago Selected Perinatal Indicators 2003 On a bar graph, the X-axis lists birth conditions and the Y-axis shows percentages. The bars labeled Austin indicate 21.1 percent teen births, 2.8 percent no prenatal care, and 14.5 percent low birth weight. The bars labeled Chicago indicate 13.5 percent teen births, 1.7 percent no prenatal care, and 10.1 percent low birth weight. Source: Chicago Department of Public Health, Chicago Health and Health Systems Project, April 2006 Slide 5 Overview of PCC History and mission Full-service community health center since 1993 330 funding, FQHC, since 2002 Model of care Family Medicine 9 of 18 Attendings with MCH/OB Fellowship Peds, OB-GYN, CNM’s, FNP’s, LCSW’s, Psych Health education and outreach Hosts MCH Fellowship and FM Residents Experience with health disparities collaboratives Slide 6 PCC UDS Data This slide contains a chart with the following headings: Year, Total Users, Prenatal Users, Deliveries, Percent low birthweight, Percent late entry to car and HIV positive prenatal users. In year 2002 the total users equal 11,359, prenatal users equal 737, Deliveries equal 445, percent low birthweight equal 15, percent late entry to care equal 8, and HIV positive prenatal users equal 0. In 2003 the total users equal 20,928, prenatal users equal 858, deliveries equal 647, percent low birthweight equal 15, percent late entry to care equal 20, and HIV positive prenatal users equal 1. In 2004 the total users equal 22,653, prenatal users equal 1,779, deliveries equal 1,083 and 836 PN users, percent low birthweight equal 8, percent late entry to care equal 44, and HIV positive prenatal users equal 2. in 2005 the total users equal 25,235, prenatal users equal 2,086, deliveries equal 1,395 and 1,064 PN users, percent low birthweight equal 9.7, percent late entry to care equal 42, and HIV positive prenatal users equal 3. Slide 7 Care Model At the top of the slide is an oval labeled Community: Resources and Policies. Within that oval is an oval labeled Health System: Health Care Organization, which contains four concepts: Self-management, Delivery System Design, Decision Support, and Clinical Information Systems. An arrow points down from the external oval to the words Functional and Clinical Outcomes. Across this arrow, near the bottom, are two horizontal two-way arrows sandwiching the words Productive Interactions. These arrows point to and from two ovals labeled Informed, Active Patient, and Prepared, Proactive Practice Team. Source: Institute for Healthcare Improvement Slide 8 Impact Analysis of PCC’s Model At the upper left of the slide is a box marked Community Problem. A rightward arrow points from it to a box marked Clinical Model, which has a rightward arrow pointing to a box marked Outcome. A solid diagonal line connects the Community Problem box to a central box marked Family Practice Model with Obstetrics, which has a dotted diagonal line connected to the Outcome box. The central box also has a solid diagonal line protruding from the lower left corner and a dotted diagonal line protruding from the lower right corner, but neither connects to anything else. A rightward arrow points to the central box from two concepts: Low birth weight, 140 out of 1,000 live births; and Very low birth weight, 39 out of 1,000 live births. Both concepts are followed by an asterisk. Another rightward arrow points from the central box to two concepts: Low birth weight, 101 out of 1,000 live births; and Very low birth weight, 9 out of 1,000 live births. Both concepts are followed by a double asterisk. An upward arrows points to the central box from a set of groups: Family Practice Residency, MCH Fellowship, Case Management, Community Nursing, and Ameri-Corps Outreach Workers. Asterisk: Austin area, 1999. Source: I-Plan data system Double asterisk: RSWH deliveries of PCC and unattached patients, June 11th, 2004. Source: Perinatal database. Slide 9 Perinatal Pilot Collaborative: Seeing wider opportunities to respond to the problem At the center of the slide are the words PCC and Partners. To the left are a set of concepts collectively labeled Influences on MCH. They are Environment, Genetic slash Familial Life Course, Maternal Preconception Health, Lifestyle slash Stressors slash Stress Response, SES Conditions and Disparities, and Prenatal Course. A red arrow points from this set to a set on the right labeled Opportunities to Positively Influence MCH. These opportunities are Social and Legal Resources, Access to Ongoing Health Care, Psychological and Spiritual Support Services, Educational and Economic Opportunities, and Environmental Safety. In between these lists are three labeled points on the line. From left to right, they are Early and Individualized Risk Assessment and Care, Concurrent and Prospective Care Management, and Networks and Collaboration. Slide 10 Plan-Do-Study-Act Method of Making Changes Identify opportunity, then champion the idea PDSA changes; more than 119 PDSA’s in Perinatal Pilot at PCC Example: Ramp-up of PDSA’s At the lower left are the words GDM Screening at Hospital OB Triage. An arrow points from them, up and to the right, to the words Algorithm to Prompt Care slash Red Folders: More Comprehensive Approach. Another arrow points in the same direction from there to the words Patient Given Specific Contact Person for Appointment: Barriers to Appointment. From there, we have diverging upward arrows. One points to the words Refined Tracking Form. The other points to the words Outreach to Patients: Follow-up Needed. Slide 11 Top 7 Changes At the Health Center Front-loaded care Prenatal sessions for all FP providers Psychosocial and depression screening; PHQ Self-management goals Performance Improvement assistant, PIA, role At the Hospital Red folders algorithm slash outreach to unattached patients Joint practice committee: pre-M and M quality assurance Slide 12 Perinatal PECS Data at PCC: July 2005 to Present Process, as of April 2006, asterisk HIV test: 100 percent Psychosocial risk assessment: 83 percent Prenatal depression screening: 78 percent SMG: 50 percent Early GDM screening: 80 percent Outcome, June 2005 to March 2006, asterisk Preterm labor: 13 percent Low birthweight: 13 percent Infant mortality: 0 Challenges Asterisk: At pilot site only; selected indicators Slide 13 Performance Improvement Program: Identified Needs At the center of the slide is a circle labeled PI, which is inside a circle labeled Team slash Task Force. Along the outside of the latter circle are six segments collectively forming a third circle. These segments are labeled Patient Satisfaction, Finance, Grants, Support Services, Clinical and Collaboratives, and Employee slash Provider Satisfaction. Slide 14 Communication and Systems Development Excerpt from PCC’s Perinatal Collaborative Aim Statement: Implementation of a patient safety system that prepares the multidisciplinary PCC and WSMC teams for high-risk patient care; antepartum, intrapartum, and postpartum; and encourages self-reporting and identification of near misses by November 2005 at PCC and WSMC Family Birthplace. How do you measure that: Existence of Processes developed and institutionalized Extend care management model into hospital Evidence-based practice tools: algorithms, protocols, drills Slide 15 PCC Community Wellness Center slash West Suburban Medical Center At the upper center of the slide is a box titled PCC Community Wellness Center. Underneath the title are listed Board of Directors, CEO and President, and Chief Medical Officer. The box also contains a ring of six boxes joined by two-way arrows, collectively labeled Fellowship Training. Clockwise, the individual boxes are labeled Erie Court Site, South OP Site, WSMC Site, Salud Site, Austin Site, and Lake Site. The Erie Court Site box forms a triangle of two-way arrows with a box labeled WSMC PHO Managed Care and an oval labeled Integrated Service Delivery Initiative. The WSMC Site box, which is a different color from the others in the ring, forms a triangle of a two-way arrows with a box labeled WSMC Family Practice Residency and an oval labeled Integrative Medical Education. An oval labeled Integrative Referral System connects with two-way arrows to the Salud Site, Austin Site, and Lake Site boxes and a lower box labeled WSMC Inpatient slash Outpatient Diagnostics. The Wellness Center box connects with two-way arrows to two other large boxes. One, labeled Target Population Reach by Risk Reduction Outreach, contains this list of six: Yellow Brick Road, Women’s Sober Living; Haymarket House, alcohol slash substance abuse; Infant Jesus Dental; UIC Dental School; Chicago Urban Ministries, counseling, housing; and Bethel New Life, social services, housing. The other major box, labeled Formal Community Collaborations, contains this list of four: Circle Family Care, Interfaith House, Westside Health Authority, and Westside Health Collaborative Care Coalition. Slide 16 Closing the Gap Programs in Chicago At the top of the slide is a box labeled Health Resources and Services Administration, HRSA: Closing the Health Gap Initiative on Infant Mortality. A bifurcating line connects it to two second-tier boxes. One is labeled Maternal and Child Health Bureau, MCHB, Risk Reduction Pilot. It leads down to a third-tier box labeled State MCH Agencies and Other Grantees, which leads down to a fourth-tier box labeled Target Population Reached by Risk Reduction Outreach. The other box on the second tier is labeled Bureau of Primary Health Care, BPHC, Perinatal and Patient Safety Pilot Health Disparities Collaborative. It leads down to a third-tier box labeled Perinatal Collaborative Pilot Sites, Then All FQHC’s, which leads down to a fourth-tier box labeled Target Population That Accesses Prenatal Care. Slide 17 Still More Needed to Close the Gap At the top of the slide is a box labeled Health Resources and Services Administration, HRSA: Closing the Health Gap Initiative on Infant Mortality. A bifurcating line connects it to two second-tier boxes. One is labeled Maternal and Child Health Bureau, MCHB, Risk Reduction Pilot. It leads down to a third-tier box labeled State MCH Agencies and Other Grantees, which leads down to a fourth-tier box labeled Target Population Reached by Risk Reduction Outreach. The other box on the second tier is labeled Bureau of Primary Health Care, BPHC, Perinatal and Patient Safety Pilot Health Disparities Collaborative. It leads down to a third-tier box labeled Perinatal Collaborative Pilot Sites, Then All FQHC’s, which leads down to a fourth-tier box labeled Target Population That Accesses Prenatal Care. Dotted lines connect both of the fourth-tier boxes to a lower box labeled Unreached Target Population High-risk for Infant Mortality, Only Accesses Emergency Services. Beneath this box is written, Dot Dot Dot, and Address Social, Economic, Environmental Disparities. Slide 18 PCC’s Plans for Collaborative Spread To other PCC sites Unattached population Assist in spread to other FQHC’s nationally Slide 19 More Plans Research to Better Understand: Role of prenatal care in improving outcomes Improved psychosocial screening and health Workforce development Model replication Integration of Services WIC slash Case management together with CHC services Behavioral health Community-based agencies