Group Prenatal Care and Group Baby Care With Refugees Roberta Matern, MD Lindsay Grizzle, MD Family Medicine Residency, St. Joseph’s Hospital and Medical Center, Phoenix, AZ April 28, 2015

Disclosures None

Objectives 1. List modifications needed to CenteringPregnancyTM and CenteringParentingTM to tailor them to refugees 2. Identify barriers to group prenatal care with refugees and discuss solutions 3. Describe how residents can be involved with these groups

St. Joes: Most patients on Medicaid Many refugees 8/8/8 program 6 faculty (4 providing OB care) Centering with refugees for 6 years (IMP – International Maternity Program)

Health assessment Education Support GROUP SETTING

Outcomes for Centering  Preterm birth rates Birth weights  Initiation of breastfeeding  Rates of contraception use  Visit satisfaction for patients and providers

Benefits with refugees MORE TIME More education Group support Community building Cultural competency education for residents Troubleshooting Increased efficiency by saying once to a group of women that which is much more time intensive if done individually & repeatedly. More time to address pt questions that many of the others might share. Greater support and empowerment amongst one another. For resident: different cultures to learn, but also ensuring proper methods of using phone or live interpreter and culturally sensitive interpersonal interaction.

Modifications to Centering Regular Centering Refugee Group English/Spanish Enrollment by EGA Pts check wt/BP Books for $20 each (English/Spanish only) 2 constant providers throughout Centering curriculum Language and culturally based groups Rolling enrollment Literacy level (we check wt/BP) No books Same attending/rotating residents (or focus on OB-minded residents) Curriculum loosely Centering based with emphasis on health and safety More in-depth syllabus/book vs. Topics (6 that repeat every 6 weeks for moms; 3 topics for baby groups) - amount info/breadth limited due to extra time req’d for interpretation and due to rolling enrollment. Topics Include: MOM 1. Health Choices in Pregnancy (foods, iron, choices) 2. Fetal Development & L&D (fetal growth, stages of labor, cervical dilation, placenta delivery) 3. What to Expect at Hospital During L&D (anesthesia, labor interventions, hospital stay, newborn screening) 4. Car Seats (securing infant, securing seat) 5. Oral Health (causes of decay, caregiver transmission of bacteria, baby bottle rot, care of teeth) 6. Postpartum Issues (menstrual cycle, non-hormonal/hormonal methods, PPD sx, bonding, BrF basics/benefits, colostrum, BrF video *all topics make use of visual aids* BABY Infant Nutrition & Feeding (BrF problem solving, intro of solids, cow/goat milk, WIC) Basic Infant Care & Safety (bathing, sleep, taking temp, tummy time, shaken baby, passive tobacco, sun safety, colic/crying) Oral Health and Infant Bonding (bacterial transmission, bottle rot, cleaning teeth, PPD screen, maternal attachment, reading) *developmental milestones & vaccinations every visit *visual aids

Curriculum Prenatal 1. Healthy Choices in Pregnancy 2. Fetal Development & L&D 3. What to Expect at Hospital During L&D 4. Car Seats 5. Oral Health 6. Postpartum Issues All with visual aids Repeats every 6 months More in-depth syllabus/book vs. Topics (6 that repeat every 6 weeks for moms; 3 topics for baby groups) - amount info/breadth limited due to extra time req’d for interpretation and due to rolling enrollment. 1. Healthy Choices in Pregnancy (foods, iron, choices) 2. Fetal Development & L&D (fetal growth, stages of labor, cervical dilation, placenta delivery) 3. What to Expect at Hospital During L&D (anesthesia, labor interventions, hospital stay, newborn screening) 4. Car Seats (securing infant, securing seat) 5. Oral Health (causes of decay, caregiver transmission of bacteria, baby bottle rot, care of teeth) 6. Postpartum Issues (menstrual cycle, non-hormonal/hormonal methods, PPD sx, bonding, BrF basics/benefits, colostrum, BrF video *all topics make use of visual aids*

Curriculum BABY Infant Nutrition & Feeding Basic Infant Care & Safety Oral Health and Infant Bonding *developmental milestones & vaccinations every visit *visual aids Repeats every 6 months Infant Nutrition & Feeding (BrF problem solving, intro of solids, cow/goat milk, WIC) Basic Infant Care & Safety (bathing, sleep, taking temp, tummy time, shaken baby, passive tobacco, sun safety, colic/crying) Oral Health and Infant Bonding (bacterial transmission, bottle rot, cleaning teeth, PPD screen, maternal attachment, reading) *developmental milestones & vaccinations every visit *visual aids

Barriers Communication Transportation Logistics Staff Training Funding Recruitment

Communication Remember, clinics that receive funds from federally funded program (Medicaid) MUST provide interpretation Live interpreters (ideal) Usually from the IRC Sometimes from state Medicaid plans Cyracom Communication --During visit – live vs. cyracom --Outside of visit – siphon calls to specific --front office person/personal phones --front office person/personal phones

Transportation Community partners IRC Catholic Charities Lutheran Social Services Medicaid taxi vouchers Probably our biggest barrier Takes a HUGE amount of staff time with phone calls/reminders/emails/etc

Logistics/Staff 1-2 attendings 1-2 RNs and/or MAs Residents and medical students Other staff dedicated to fielding calls from refugees and coordinating appointments and rides Adept with Cyracom AND the system AND the agencies CLINIC, RESIDENCY, MANAGERS AND EVERYONE FROM CMO DOWN HAS TO BE ON BOARD Coordination of care --largely takes place during the visit (depends on level of IRC involvement)

Training/Funding Revolving door of residency faculty Centering workshops Usually on faculty’s own CME dime March of Dimes First Things First Innovative grants Phoenix Children’s Hospital  

Recruitment Not easy to get enough patients Community partners Visit communities CHC IRC Lutheran Social Churches Word of mouth Prior patients

Resident involvement 1-2 teaching sessions on facilitation and Centering per year R2/R3 with interest in OB Each session with the same 1-2 attendings as co-facilitators Review language, culture, curriculum, props and plan prior to session Reinforces use of interpreters, facilitation skills, use of patient-friendly and culturally-friendly language

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