PUTTING IT ALL TOGETHER · PUTTING IT ALL TOGETHER: MELDING OUR PASSION & KNOWLEDGE TO ACHIEVE EXCELLENCE Presentation by Kay Johnson For the Maternal and Infant Health Center of

PUTTING IT ALL TOGETHER: MELDING OUR PASSION &

KNOWLEDGE TO ACHIEVE EXCELLENCE

Presentation by Kay Johnson

For the Maternal and Infant Health Center of Excellence Annual Meeting

NYS DOH, Bureau of Women, Infant and Adolescent Health (BWIAH) Provider Day

May 10, 2017

Session Objectives - Participants will:

Become familiar with the core elements of service systems for women and infants. Review why increased health equity can improve outcomes for women, infants, and families.Reflect on the potential for using data and forging better partnerships.Envision change.

K Johnson. NYS. May, 2017

For decades many believed that if we improved access to and use of effective contraception and quality prenatal care, then we could improve outcomes in the health of women and infants.

This is true in some ways BUT

Now we know much more needs to be done to address cumulative disadvantages and inequities that occur over the life course of many women of childbearing age.




So, what is not happening that should be? Low reproductive health awareness or no “reproductive

life plan” for most men and women. Young adults in working class still uninsured. Primary care discontinuous (no medical home). Majority of women have coverage for well visits with

preconception care, but they and their providers are not aware, not benefiting.

Many providers not focused on reproductive risks, preconception health, or recurring risks for adverse pregnancy outcomes.

Unequal treatment and health inequities drive racial/ethnic and income disparities.

Common system failures Primary care providers not strong on preconception.Prenatal care quality receives too little emphasis.Interconception care devolves into LARC initiatives.Prevention of teen pregnancy but not weathering.Head separated from the body (oral & mental health).Perinatal HIV, opioid use, etc. marginalized.Perinatal QI mainly about hospitals and vital statistics.Home visiting not enough to affect index birth

outcome.Developmental screening not done as recommended.SDOH & ACEs assessed but not addressed.



SACIM Strategic Directions: 6 Big Ideas• Improve the health of women before, during, and

after pregnancy• Improve the health of women before, during, and

after pregnancy1• Ensure access to a continuum of safe and high-

quality, patient-centered care• Ensure access to a continuum of safe and high-

quality, patient-centered care2• Redeploy key evidence-based, highly effective

preventive interventions to a new generation• Redeploy key evidence-based, highly effective

preventive interventions to a new generation3• Increase health equity and reduce disparities by

targeting social determinants of health• Increase health equity and reduce disparities by

targeting social determinants of health4• Invest in adequate research and data to measure

access, quality, and outcomes• Invest in adequate research and data to measure

access, quality, and outcomes5• Maximize interagency, public-private, and multi-

disciplinary collaboration• Maximize interagency, public-private, and multi-

disciplinary collaboration6


1. Improve the health of women

• Quality prenatal care• Access to interventions for

risk management• Effective birth & perinatal

systems

• Quality postpartum & ongoing well woman visits

• Family planning• Interconception care for

identified risks

• Primary care • Family planning• Health promotion and

community preventive services

• Primary care with preconception components

• Family planning• Community preventive

services

Before pregnancy

No pregnancy

During pregnancy

Beyond pregnancy


Percent of Adults Age 18-64 with No Usual Source of Care, By Insurance Status, US, 1997-98 to 2013-14


0

10

20

30

40

50

60

70

Insured continuously all 12 months Uninsured for any period up to 12 months

Uninsured more than 12 months


2. Ensure access to a continuum of safe and high-quality, patient-centered care


Patient centered

Safe

Timely

Effective

Efficient

Equitable

IOM. Six Domains of Health Quality. Crossing the Quality Chasm. 2001. http://www.nationalacademies.org/hmd/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.htmlhttp://www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmSixAimsforChangingtheHealthCareSystem.aspx

Six Domains of Health Quality

Adopt Systems Integration Strategies

Array of services and supports

What is the process magic

in those arrows?

Client Centered Approach


Connections for a continuum of care

Before

pregnancy

During pregnancy

Beyond pregnancy


• Are stand-alone family planning, private OB-GYN, private primary care, and FQHC connected?

• How are women at-risk connected to home visiting?

• How does prenatal information reach the birth setting?

• What connects postpartum/ well-woman visits, family planning, lactation support, and interconception care?

Use the power of “ONE”

One key question

One medical home

One plan

One care coordinator lead

One stop shopping


3. Redeploy effective, preventive interventions • Social marketing, health

education, and access to clinical and community preventive services. 1. Immunization2. Family planning3. Breastfeeding4. Safe sleep 5. Smoking cessation

What else?• Newborn screening• Folic acid• 17P• Developmental screening• HIV screening & ARV


Source: SACIM (2013) Recommendations for Department of Health and Human Services (HHS) Action and Framework for a National Strategy. Strategic Direction 3. https://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/Correspondence/recommendationsjan2013.pdf

Implement “Two Gen” approaches


To learn more, visit:http://ascend.aspeninstitute.org/pages/the-two-generation-approach

4. Increase health equity and reduce disparities by targeting SDOHNot all health differences are health disparities.Health disparities are systematic, plausibly avoidable

health differences according to income, race/ethnicity, religion, or socioeconomic position.Disparities in health and its determinants are the

metric for assessing health equity. Health equity is the principle underlying a

commitment to reducing disparities in health and its determinants.Health equity is social justice in health.


Source: Braveman et al. Health Disparities and Health Equity: The Issue Is Justice. Am J Public Health. 2011;101:S149–55.

HEALTH

Behaviors Medical Care

Living & Working Conditionsin Homes and Communities

Economic & Social Opportunities and Resources

-Reduce poverty & segregation. -Promote economic development in disadvantaged communities.-Promote child & youth development & education, infancy through college.-Job creation & training.

Promote healthier homes, neighborhoods, schools & workplaces.Strengthen safety nets.

Source: P. Braveman et al. University of CA., San Francisco, adapted from version originally created for: Overcoming obstacles to health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. Robert Wood Foundation, 2008.

Interactions between genes and experiences

Achieving health equity by addressing SDOHK Johnson. NYS. May, 2017

Income/ Poverty

Racism

Housing/ Neighborhood

Social support

EducationStress, trauma,

ACE

Employment

Safety/ violence

Exposure to hazards

WHO defines SDOH as the circumstances in which people are born, live, and work, and the systems in place to deal with illness. Circumstances shaped by larger forces such as economics, public policies, and politics.

Social Determinants of Health


How can we tackle SDOH?

Tax policy

Family leave

ACEs

Medical-legal partnerships

Housing policy

Health in all Policies


Family Tax Credits Improve OutcomesK Johnson. NYS. May, 2017

Improved maternal and infant health

Better school performance

Increased college, work and earnings in next

generation

0 10 20 30 40 50 60 70 80 90 100

Married

Non-Hispanic White

Non-Hispanic Black

Hispanic

< High school education

High-school degree

Attended college

Percentage of US Women on Maternity Leave and Giving Birth by Marital Status, Race-ethnicity, and Education, 1994-2015

Mothers on maternity leave Mothers giving birth

Source: Zagorsky. Divergent Trends in US Maternity and Paternity Leave, 1994-2015. AJPH Mar; 107(3):460-465. Based on Current Population Survey and US Vital Statistics data. All significant differences <.01.


Select Adverse Childhood Experiences (ACEs) Among Children 0-5

36.7% 36.9% 31.3%

12.9%22.2% 32.8%

Child less than 2 yearsof age

Child is 2-3 years old Child is 4-5 years old

Analysis of National Survey of Children's Health. NSCH 2011/12. Child and Adolescent Health Measurement Initiative (CAHMI), Data Resource Center for Child and Adolescent Health. *Nine adverse experiences include socio-economic hardship, divorce/parental separation, household member with substance/alcohol problem, victim or witness to neighborhood violence, household member with mental illness, domestic violence witness, incarcerated parent, treated unfairly due to race/ethnicity, and death of parent.

CHILDREN AGE 0-5 IN POVERTYALL CHILDREN AGE 0-5

23.0% 26.0% 23.6%

6.1%13.3% 18.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Child less than 2 years ofage

Child is 2-3 years old Child is 4-5 years old

2 or moreACEs1 ACE


Quality improvement

Performance & results

Research & evaluation


5. Invest in adequate research and data to measure access, quality, and outcomes

Adapted from IHI: Solberg et al. The three faces of performance measurement: improvement, accountability, and research. The Joint Commission Journal on Quality Improvement. 1997;23(3):135‐147.

Three Types of Measurement

Quality ImprovementQuality Improvement

Performance & Results Accountability

Performance & Results Accountability

Evaluation & ResearchEvaluation & Research


- Use of LARC- Unequal

treatment of neonates

- Key elements of postpartum visits

- Develop-mental screening referrals

Rates for:- Unintended

pregnancy- Births in risk

appropriate facility

- Postpartum visits- Develop-mental

screening

- What is the reproductive experience of women using LARC?

- How does NICU environment affect infant?

- What motivates postpartum visits?

- Validate tools for developmental screening

ACOG-NCQA-PCPI Postpartum QI MeasurePercentage of patients, regardless of age, who gave

birth during a 12-month period who were seen for postpartum care within 8 weeks of giving birth.

Patients receiving all the following at a postpartum visit: Breastfeeding evaluation and education, including patient-

reported breastfeeding Postpartum depression screening Postpartum glucose screening for gestational diabetes patients Family and contraceptive planning and education

American Congress of Obstetricians and Gynecologists (ACOG), National Committee for Quality Assurance (NCQA), Physician Consortium for Performance Improvement® (PCPI) Maternity Care Performance Measurement Set (2012) https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternity.pdf


Monitoring with Focus on Health Equity

Monitoring Health Equity & Social Determinants of Health for Mothers,

Infants, & Families

Monitoring Health Equity & Social Determinants of Health for Mothers,

Infants, & Families

Maternal &/or Infant Overall Population

Maternal &/or Infant Overall Population

Monitoring Across

Populations

Monitoring Across

Populations

Monitoring population health

Monitoring population health

Perinatal data,

including vital statistics,

clinical data, program

evaluations

Perinatal data,

including vital statistics,

clinical data, program

evaluations

Use PRAMS to monitor stress, housing, hunger, income, etc.Use PRAMS to monitor stress, housing, hunger, income, etc.

Use BRFSS data to monitor ACEs and other life course events

Use BRFSS data to monitor ACEs and other life course events

Work on data linkages (vital records, housing, Medicaid, welfare, etc.)

Work on data linkages (vital records, housing, Medicaid, welfare, etc.)

Build and use data warehouses, etc.Build and use data warehouses, etc.



0

5

10

15

20

25

30

35

40

45

50

No stressors 1-2 stressors 3-5 stressors 6-13 stressors

Perce

nt

Percentage of Women with Pregnancy Stressors, By Medicaid Status, NY and NYC, PRAMS, 2011

PRAMS Medicaid

PRAMS Non-Medicaid

NY Medicaid

NY Non-Medicaid

NYC Medicaid

NYC Non-Medicaid

Source: Prepared by Johnson. https://nccd.cdc.gov/PRAMStat/

6. Maximize interagency, public-private, and multi-disciplinary collaboration


What are their roles & what partnerships?

Woman and her family

Primary & OB-GYN

Care

Family Planning

Clinic

Home Visiting

Mental Health

Provider

Lactation & WIC

nutrition

CommunityHealth

Workers


HousingIncome

& Social Support

Early Care & Education

Employment & Job

Training

Maximize Partnership Synergy

By combining the perspectives, resources, and skills of partnership, the group creates something new and valuable together – a whole that is greater than the sum of its individual parts.”


Lasker et al. Partnership Synergy. Milbank Quarterly. 2001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751192/

18%

Committed Activists

16%

Equity Advocates

23%Health Egalitarians

LOW

HIGH

NONE

HIGHGOVERNMENT ROLE

17%DisinterestedSkeptics

PERSONAL HEALTHIMPORTANCE

14%

Private-sector Champions

12%Self-reliantIndividuals

Source: Exhibit 1. Bye L, Ghirardelli A, & Fontes A. Promoting health equity and population health: How Americans’ views differ. Health Affairs, 2016, Nov;35(11):1984. American Health Values Survey. RWJF.

Typology of Americans’ Health Values

4%

96%

46%

7%15% 17%

7%

94%

42%

9%17% 17%

67%

97%

80%

36%

53% 54%

HealthEgalitarians

Equity Advocates CommittedActivists

Self-reliantIndividuals

DisinterestedSkeptics

Private-sectorChampions

American’s Beliefs About Racial-Ethnic-Income Group Health Care Access Disparities, By Population Segments,

American Health Values Survey, 2015-16African Americans have harder accessLatinos have harder accessLow-income Americans have harder access

Source: Exhibit 3. Bye L, Ghirardelli A, & Fontes A. Promoting health equity and population health: How Americans’ views differ. Health Affairs, 2016, Nov;35(11):1984. American Health Values Survey. RWJF.



Envisioning the future

Looking ahead, what can New York do?• Accelerate improvement in women’s health,

before and after pregnancy.1• Improve access to a continuum of quality services

by strengthening systems of care, reducing gaps.2• Redeploy effective preventive interventions by

implementing coverage of preventive services.3• Increase health equity through data, training,

programs, systems, and policies.4• Invest in all three types of measurement and use

data for change.5• Maximize partnerships, build bridges and broaden

understanding.6


A Vision for Improving Preconception Health and Pregnancy OutcomesAll women and men of childbearing age have high

reproductive awareness.

All women have a reproductive life plan.

All pregnancies are intended and planned.

All women of childbearing age have health coverage.

All women of childbearing age are screened prior to pregnancy for risks related to outcomes.

Women with a prior adverse pregnancy outcome have access to interconception care to reduce their risks.


A Vision for Maternal and Child Health

We envision an America where all children and families are healthy and thriving, and where every child and family have an equitable opportunity to reach their full potential.


“…because the responsibility is mine and I must, I take a very firm hold on the handles of the baby carriage and I wheel it into the traffic.”

Grace Abbott 1935


http://ssacentennial.uchicago.edu/features/features-graceabbott.shtml

Documents

PUTTING IT ALL TOGETHER · PUTTING IT ALL TOGETHER: MELDING OUR PASSION & KNOWLEDGE TO ACHIEVE EXCELLENCE Presentation by Kay Johnson For the Maternal and Infant Health Center of