IMPLICIT’s Prescription for Healthy Families: Improving Birth Outcomes Through Interconception Care at Well Child Care Visits Daniel J. Frayne, MD (Asheville, NC) Joshua H. Barash, MD (Philadelphia, PA) Stephanie E. Rosener, MD (Middlesex, CT) Wendy Brooks Barr, MD, MPH, MSCE (Lawrence, MA) Sukanya Srinivasan, MD (Pittsburgh, PA) STFM Spring Conference, Seattle, WA April 26, 2012

The Problem – Preterm Birth US Preterm Birth Rate (2009) = 12.18% National Center for Heath Statistics, Dec 21, 2010 Half of pregnancies in the U.S. are unintended By the time women enter prenatal care, it is often too late to affect birth outcomes

FMEC: IMPLICIT Interventions to Minimize Preterm and Low birth weight Infants using Continuous Improvement Techniques Network of FM residency programs (since 2003) Initially focused on evidence based prenatal care New project is interconception care (ICC) at well child visits 20 participating sites in network 4 have officially begun the ICC initiative: Lancaster, Asheville, UPMC St. Margaret’s and UPMC Shadyside

IMPLICIT ICC Model Areas of Focus: Incorporate maternal assessments into WCV’s Mothers visit the office regularly even if they do not seek care for themselves1 Achievable and acceptable to women based on pilot studies2 Delivered by primary care providers Areas of Focus: Family Planning and Birth Spacing Depression Screening Smoking Cessation Multivitamin and Folic Acid Supplementation 1 Kahn and Wise, Pediatrics, 1999. 2 Gjerdingen et al., Ann Fam Med, 2009.

Baseline Survey Content 25 questions Multiple choice English and Spanish Acceptability of discussing mother’s health at WCV Topic areas in mother’s health behaviors and physician inquiry Demographics Folic acid use Depression Contraception/Pregnancy Smoking

Preliminary Survey Findings Confirms risks for poor subsequent birth outcomes are present Suggests that ICC is being delivered but infrequently 38% of smokers were not advised to quit 38% not asked about depression 45% no folic acid recommended 56% not asked about contraception The good news! 94% of all mothers were willing to accept advice from their child’s physician

Implementation: Making the model work Different sites, different challenges Dyad care ideal, but… Mothers who are NOT part of practice Different PCP and/or uninsured Vitamin dispensing Contraception access Mental health resources Time, efficiencies

NC Folic Acid Campaign Point of care distribution doubled % taking at 9 months Bigger impact on Latinas and women <25 Cost effective intervention $1.15/100 ct wholesale OTC product, naturiceutical No iron, very low risk No minerals, small and easy to swallow State law only regulates prescription samples

Example Processes Family Medicine Residency Lancaster, PA St. Margaret Family Medicine Residency Pittsburgh, PA Family Medicine Residency Asheville, NC

Negative Screen Pos screen: brochure and open mom’s chart Mother presents with child (age 0-2) for well child visit Smarphrase .icc performed by provider during child’s exam Negative Screen Usual well child care Pos screen: brochure and open mom’s chart Mother Reports Smoking Smoking Cessation Resources and Quit Line Information given to mother Mother not taking daily PNV Rx for prenatal vitamin or give supply of prenatal vitamins to mother Positive screen for Depression Assess for suicidal ideation Negative Schedule follow-up appointment or send referral form to PCP/prescribe meds Positive Assess need for immediate intervention Lack of Family Planning Inform mother of recommendations to wait until 18 months to conceive Provide contraceptive information and /or schedule follow-up visit Dyad care is the norm, uses EPIC

Flowchart Complete algorithm to handle possibilities where mom is not patient – always able to do something…

.stmicc Don’t forget to document please Documentation using EPIC at UPMC St. Margaret’s

Display toolbox Display toolbox

Each Mom leaves with a “prescription” for THEM

Continuous Quality Improvement Data collection Drives improvement Pooled into collaborative Resident involvement Teaching future leaders

Future More IMPLICIT sites to begin ICC Improve model with experience Demonstrate effectiveness/value Expand to non-IMPLICIT sites Other FM residencies Private FM practices Pediatric practices

Pennsylvania and North Carolina Chapters Thanks to our Partners National & Pennsylvania and North Carolina Chapters