Maternal Child Health “MCH Rocks” Blanca Baldoceda MD, MPH Mark Loafman MD, MPH Antoinette Lullo DO Mark Rastetter MD TJ Staff MD, MPH (virtual attendance) Katrina Tsang MD Maternal Child Healthcare: Integrating clinic & hospital into a community-oriented patient-centered medical home

Objectives for today Learn how to enhance the role of family physicians in addressing persistently poor MCH outcomes while increasing MCH workforce Learn an approach to apply faculty leadership in performance improvement to align training, the clinic, and hospital with patient centered care Gain knowledge about how to integrate a comprehensive MCH model of care into residency, fellowships and other training programs ML

Outline Maternal Child Health (MCH) defined State of MCH outcomes Rationale for MCH FM model o Philosophical commitment to social justice o Health care trends Our experience Application in your setting MLMR

Models for Primary Care: “Evolving practice model medical home” Primary Care Patient, Family and Community Generally healthy, basic needs met Socially disadvantaged, chronically ill Mental Health, Under-insured MRML MR

Maternal Child Health o Not “doing OB” o Not pediatrics o Comprehensive Family Medicine MCH continuity, not L&D continuity Patient centered o Individualized Community oriented Local population health needs (not just RRC) Plays to strengths of Family Medicine MRMLBB

Global, National, Local Perspective Global: Millennium Development Goals Renewed focus on maternal & child health Social justice, human rights, economic development Require more than just emergency obstetric care National Maternal mortality numbers worsening Significant racial, ethnic, and SES disparities Comprehensive women’s health Local Your Reality MRBB

Disparities in Maternal Child Health Outcomes Global rankings Where success has been o NICU, steroids, infection control o Antenatal diagnosis of genetic anomalies o L&D safety o Maternal critical care, medical management o Infertility Rx Disparities persist…… Routine prenatal care BBTL

Racial & Ethnic Disparities Infant Mortality - USA Deaths Per 1,000 Live Births Year 2010 Goal TL

Racial & Ethnic Disparities Low Birth Weight < 2500g USA Percent of Live Births Year 2010 Goal TL

Racial & Ethnic Disparities Very Low Birth Weight <1500g USA Percent of Live Births Year 2010 Goal TL

Racial & Ethnic Disparities Infant Mortality USA Per 1,000 Live Births NCHS 2006 Year 2010 Goal TL

Racial & Ethnic Disparities Causes of Infant Deaths Per 1,000 Live Births NCHS 2001 TL

Contemporary Prenatal Care Too Little, Too Late? What’s the focus? o Genetic screening o Medical risk assessment o Psychosocial screening What determines poor MCH outcomes? Preconception visit recommended, but… Disparity population often enter care late Who gets early care? Content of Prenatal Care inadequate? TLMR

7.1 Prenatal Care? NCHS MR

Maternal Smoking? NCHS MR

SES? NCHS MR

Racial and Ethnic Disparities Multiple Determinants of Birth Outcomes Shiono et al AJPH 1997 Controlled for 46 risk factors (demographic characteristics, medical risks, psychosocial, occ/env exposures). These 46 risk factors explained less than 10% of racial/ethnic variation in birthweights. So, 90% of low birthweight deliveries are not explained or predicted by standard medical risk assessment, and routine care. MRML

Life Course Perspective A way of looking at life not as disconnected stages, but as an integrated continuum Sounds like family medicine ML

Life Course Perspective Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7: ML

Stressed vs. Stressed Out Stressed Out Hypertension & cardiovascular diseases Glucose intolerance & insulin resistance Infection & inflammation Atrophy & death of neurons in hippocampus & prefrontal cortex Stressed Increased cardiac output Increased available glucose Enhanced immune functions Growth of neurons in hippocampus & prefrontal cortex ML TL Is our health workforce up to the task?

MCH Workforce Issues Inadequate Numbers and Scope OB/Gyn o Those who do deliver (set #, low risk, well insured) o New graduates increasingly sub-specializing MFM o Tertiary care, focused involvement Midwives o Low risk, reproductive care only APN’s o Low risk, no L&D Pediatrics o New grads increasingly sub-specializing Family Physicians TL

MCH and Family Medicine Tend to go where we are needed o Serve populations with disparate outcomes o Not always enough help Boundaries for low risk? o History poor outcome, medical problems, teens o Not always enough help Working in comprehensive health homes o Team approach with additional needed services o Positioned to address life-course continuum TLML

Challenges for Family Medicine OB Skill, training and competency Supportive and prepared colleagues Supportive and prepared institutions Turf battles Systems of care Funding Malpractice ML

Challenges = Opportunities: Aligning with the Future Guiding Vision: Patient centered care Medical Home o Comprehensive Health Home Physician-Hospital Collaboration o Responding to Trends in Health Care o Clinical Integration o Risk Management Professional and Faculty Development ML

Guiding Vision: Patient-Centered Care The “High” Road less Traveled Institute of Medicine 2001 o Safe o Timely o Effective o Efficient o Equitable o Patient Centered National Quality Agenda 2009 o Safety o Chronic Care Coordination o Overutilization o Population Health o Patient/Family Engagement o Palliative Care NOTHING HERE ABOUT “TURF BATTLES”, OR “THE WAY WE HAVE ALWAYS DONE IT”, OR THE RESIDENTS DON’T WANT TO “DO OB” MR ML

Guiding Vision: Patient-Centered Care The “High” Road less Traveled Comprehensive Health Home Clinical Integration Align on quality and resources Care Coordination - Planned Care Physician-Hospital Collaboration Risk Management MRML

Clinical Integration An interdependency among providers, with a vested interest in the performance of one another, such that their incentives are closely aligned to meet common objectives. Federal Trade Commissioner, April 2009 What does it look like? Rigorous use of clinical practice guidelines Using ancillary personnel at highest level Standardized templates, approach Measuring, responding to performance data ML

Risk Management Managing Risk Altering the trajectory for poor outcomes Risk avoidance.... NOT All in this together Outreach, screen and identify (with innovation) Team approach Systems (tools and processes) Training and Faculty Development Performance Improvement/Quality Mgmt Measure/respond to data (transparency) Federal or Hospital Coverage really helps ML

Responding to Challenges: Aligning with the Future Guiding Vision: Patient centered care Medical Home o Comprehensive Health Home Physician-Hospital Collaboration o Responding to Trends in Health Care o Clinical Integration o Risk Management Professional and Faculty Development MLBB

Professional – Faculty Development Core Areas Clinical Scholarly Leadership BB

Clinical o Women’s Health o Maternity Care  Medical (conditions we manage for all anyway)  Psychosocial (stuff that isn’t getting done without us)  Interconceptional care o Labor and Delivery  Perinatal Conditions and Risks in addition to normal  Operative Obstetrics (1 in 3 to 6 pregnancies) o Child Health  Newborn period  Birth to age 1  Parenting support, anticipatory guidance Professional – Faculty Development Core Areas BBML

Clinical Scholarly o Translational Research (putting what we know into practice)  $$$$ and Need o Performance Improvement  Quality, Clinical Integration  EBM, Comparative Effectiveness  Safety, Risk Management o Psychosocial Determinants  Lifecourse Perspective Professional – Faculty Development Core Areas ML TL

Clinical Scholarly Leadership o Clinical Services  Establish credibility and expertise  Maintain primary care role with all patients (CVD) o Quality, Safety, Performance Improvement  Infiltrate existing areas, develop new venues o Teaching and Training  Students, Residents, Fellows, Faculty and Community Docs Professional – Faculty Development Core Areas TLML

MCH Model Our Approach What o MCH care model for at risk urban population o Community Health Center network (FQHC) o Family Medicine training program How o Large resident/faculty group practice teaching service o Guided by performance improvement processes (extensive) o Collaboration with OB/Peds/Neo/MFM/Hospital Who o Family Physicians with enhanced training & mentoring o Residents, Fellows and Students o RN, CNM, APN, LCSW, health education/ outreach o Care management team ML

Breakout Session 1 What will you implement at home, and teach while doing? What do our MCH patients need that we can provide to enhance: Outcomes Our program Our hospital and colleagues Just the WHAT, not “HOW” – yet“Blink” Take the patient centered MCH “high road” ML

What will you implement at home, and teach while doing? Improve access to care Improve communication Group visits for prenatal care Improve psychosocial outcomes, resources Train providers, preceptors (identify knowledge gaps, acknowledging the gaps) Increase support for patients Reduce teen pregnancies Improve nutrition of pregnant moms Improve continuity of prenatal care at Pregnancy Care Center Identify minority population needs

Breakout Session 2 How will you implement this strategy, and teach while doing. Specify: High Road outcome or goal Examples Identify Strategic Partner(s) What is the tie that binds (alignment) Name the Primary Venue or Forum Identify Looming Barriers Name the critical first step(s) ML MR

Sample Tools

Bringing it All Together Opportunities back home Vision: Patient Centered Care Responding to the Needs Preparing for health care reform Improving outcomes Developing clinical scholars and leaders Training tomorrows workforce MR

Questions & Comments Maternal Child Healthcare: Integrating clinic & hospital into a community-oriented patient- centered medical home