CPSP Postpartum Care

CPSP Annual Meeting

November 14, 2013Mary Wieg, PHN, MBA, Nurse Consultant IIIMaternal, Child and Adolescent Health Division

Center for Family Health

California Department of Public Health

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Objectives

Participants will be able to:

1) Describe the need to improve postpartum care

2) Describe the requirements for improving CPSP Postpartum Care in the MCAH Scope of Work

3) Access the sample assessments on the CPSP Web site

4) Identify techniques to assist providers in implementing requirements

5) Plan next steps for working with providers to implement

improvements.

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Why Improve CPSP Postpartum Care?

• CPSP women tend to be high risk• Many women still will lose coverage after the 60-

day postpartum period• Many women don’t return for postpartum care.• Postpartum is an excellent time to educate

women about the importance of interconception health and link them with continuing services.

• Reduce risks in future pregnancies by addressing risk factors

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Interconception Risks

Recurrence risk varies by diagnosis, but is significant:

• 15 to 30 percent for Preterm Delivery

• 20 to 60 percent for Pre-Eclampsia

• 2-12 fold risk for Low Birth Weight infants

Closely spaced pregnancies (<18 months) are associated with increased complications:

• Low Birth weight, Small Size for Gestational Age, Preterm Birth; Rapid Repeat Birth (<6 months between pregnancies) Infant Death.4

Postpartum Risks

• Perinatal mood and anxiety disorders (PMAD) – 15.3 % experience postpartum depressive

symptoms (MIHA, 2011)– 10% experience more severe PMAD*– Increases to 25% if history of PPD*

• Breastfeeding difficulties• Medical issues

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Postpartum Needs

• Medical follow up• Psychosocial assessment/follow up• Breastfeeding support• Family planning• Infant care instruction—46.8% always or

often bedshare, 66% put baby on back to sleep (MIHA 2011)

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Attendance at Postpartum Care

In 2011 (HEDIS 2012):• 61.7 percent of Medi-Cal Managed Care

clients attended a postpartum visit*, • Wide variation by county: High is 77.6

percent, low is 43.8% (see handout)*

Compared to:• 83.6 percent of women with commercial

coverage.*

Yet, women on Medi-Cal are at higher risk!

*DHCS HEDIS performance measure results, 2012 7

Review of CPSP Postpartum Assessments

• Title 22 requires that the postpartum assessment cover the same areas as the initial/trimester assessments.

• In 2011 review of postpartum assessments, many assessments were missing important items.

• PHCC concurrently developed interconception guidelines

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Items missing from one or more PP assessments

Birth Outcome: gender, birth weight, GA, delivery method, any maternal complications

Health Education: Environmental/Occupational exposures

Dental (mother and baby)

Follow up of medical problems

Postpartum discomforts

Infant care/safety (SIDS)

Family Planning: Plans for future children

Assessment for reproductive coercion/ BC sabotage

Psychosocial: Follow up of MH issues

Coping with demands of baby

PMAD screening

Relationship health

Substance use (AOD, smoking)

Nutrition: BMI

Support for Breastfeeding

Required referralsFamily planning, Dental, WIC, genetic screening, CHDP

Other referral: perinatal home visiting 9

PHCC Interconception Guidelines

• Improving preconception and interconception health to improve birth outcomes is a strategic priority of MCAH, HRSA, CDC, ACOG and the March of Dimes

• 2006: formed the Preconception Health Council of California (PHCC)

• MOD, ACOG District IX and PHCC developed evidence-based guidelines for interconception care.

• MCAH is promoting these in CPSP

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Interconception Care Project of California (ICPC) Content Areas

• Alcohol Use*• Anemia• Domestic Violence*• Gestational Diabetes• Gonorrhea and Chlamydia• Hepatitis• HIV• Chronic Hypertension• Migraine• Overweight/Obesity*• Postpartum Depression*

• Preeclampsia• Preterm Birth• Cesarean Section• Seizure• Substance Use• Syphilis• Thrombocytopenia• Thyroid Disorder• Tobacco Use*• Vaccinations

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ICPC prevailing messages

Three standard interconception messages that ALL women should receive at the post-partum visit

Messages printed on Patient Algorithms and Provider Handouts

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SOW 2.9 Requirements

• Work with MCAH and CPSP providers to maximize the quality and utilization of postpartum care– Revise postpartum assessment forms and

protocols• PHCC Interconception Guidelines

– Perinatal depression– Reproductive coercion/birth control sabotage– Improving support for breastfeeding

• http://www.everywomancalifornia.org/postpartumvisit

• Report activities in the Annual Report15

Next Steps

• Share this information with your providers• Encourage them to incorporate the

interconception guidelines into their practice

• Resources provided to facilitate this• Report activities and provider response in

the Annual Report

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Resources

Available on the CPSP Web site• Insert “cdph.ca.gov/cpsp” into search engine

– PSC Forms for Local Use

• Two assessment form formats– Integrated assessment and care plan (two-column form)– Separate Assessment and Care Plan forms

• Handout on missing items can be an aid for modifying assessments and protocols

• Refer to online provider training for recommendations.

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Discussion

1) What techniques have you found helpful in encouraging providers to incorporate practice improvements?

2) What are some next steps you can take to help providers to implement improvements?

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