Virginia Van Duyne, MD, Sara Shields, MD and Navid Roder, MD Integrating Interconception Care (ICC) into the Family Health Center of Worcester’s Early Well Child Visits Virginia Van Duyne, MD, Sara Shields, MD and Navid Roder, MD

Objectives Participants will be able to: Describe Interconception Care (ICC) and the goals of integrating ICC screening into well child visits. Understand how continuous quality improvement techniques can be used to create real process change in the implementation of ICC screening.

What is Interconception Care? An emerging concept for focusing on the health of a woman from the postpartum period up until her subsequent conception Family physicians are perfectly poised to do this (dyad care)

Why Interconception Care? Preterm birth (PTB, <37 wks) is the #1 cause of neonatal mortality & morbidity Low birthweight (LBW, <2500g) is being linked to adult morbidities Emerging studies link depression, short interpregnancy interval to these risks 50% of smokers who quit in pregnancy relapse within 6 months postpartum (CDC) 2 BIG PROBLEMS: PTB: Causes 50% of all pediatric neurodevelopmental problems LBW: CAD, DM2, obesity Despite our traditional prenatal interventions, low birth weight and prematurity have not decreased Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. The Cochrane Database for Systematic Reviews. Volume (3), 2004.

What do we do in ICC? Target modifiable risk factors: Smoking Depression Folate supplementation Lack of contraception Integrate ICC into well child visits Collect data using CQI IMPLICIT network Target modifiable risk factors: Integrate ICC by screening moms while they are at well child visits between ages 0-2. capturing the moms who might not otherwise be seen in office while they are coming in with their children anyways. Collect data- use IHI’s CQI method of PDSAs to improve our process and collect data. Then pool our data with IMPLICIT network (Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques) Nationwide network of 16 family medicine, health center-based residency programs Pooling data together for larger n to study effect of ICC on outcomes

Process Change IHI Model for Improvement Plan-Do-Study-Act cycles From Pilot to Implementation Process! Process! Process! Sounds like a good idea, right? Going from the good idea to making that new process a part of everyday clinical life is another matter. As part of the resident QI curriculum, we studied IHI’s Model for Improvement and set out to create some change. This model uses small iterations of a Plan-Do-Study-Act cycle to test a change, study it and test another small change until you see improvement

Done by MA We took a really close look at the process and found that mapping out the steps of the process both clarified each team member’s role in ICC screening, and also provided a means of quickly getting other teams on board with the screening process.

No Folate Create Prescription/ Referral Wants prescription or referral? Counsel on why folate Open mom’s chart (name is on questionnaire) Smoking Lack of Contraception Positive Screen *Document in child’s chart under Assessment (V65.40), copy & paste “Pos Screen for ___” from Template saved to desktop, fill in blanks Get Soc Services involved, refer to EMH Counsel on options Complete PHQ-9. Suicidal? 5A’s: ask, advise, assess, assist, arrange Routine well child care Yes No Depressed (PHQ-2 positive) Create encounter for mom: MA brings name, DOB to scheduler Routine well child care while await mom’s registration Open mom’s chart , create Office Visit Complete note in mom’s chart AND document in child’s chart under Assessment (see *) Notify OB advocate and schedule follow-up with PCP Place paper questionnaire in folder in resident office This is the second part of the process: what to do with a positive screen.

Real Process Change After multiple iterations, over about 6 months’ time, we were able to observe a real change in our process as seen on our run chart here. Looking at implementing screening in my own practice we went from a baseline of 0 screening to ultimately a 100% screening rate for more than a month.Using the QI method, this is considered significant change since it follows one of the rules of nonrandom patterns: a shift in the process is indicated by six or more consecutive points above or below the median.

What we found… 59% of the 34 screens done were positive for 1+ risk factor #1 most common risk factor identified: Lack of vitamins (59%) #2: Lack of contraception (25%) We made some interesting observations in our ICC screening pilot and implementation. In the pilot phase, we found that over half of the time that we screened moms, there was a need (lack of contraception, vitamins, positive depression screen or smoking). The most common risk factor we found was lack of vitamins (59% of positive screen items were positive for lack of vitamins) and second-runner up was contraception (25% of positive screen items were positive for lack of contraception).

What we found… Depression and smoking had high rates of recurrence in the interconception period Depression: 43% (n=7) Smoking: 75% (n=4) Also, of the moms with a reported h/o depression, nearly half of them reported a recurrence of depressive symptoms in the interconception period. Similarly, 75% of moms who had a h/o smoking screened positive for current tobacco use. This speaks to the importance of ICC screening.

Ongoing work One part-time provider Oct 2012-Feb 2013 43 well child visits age 2 and under 15 with ICC screening done (35%) Another 10 with mom visit at same time (group or other)—25 total (58%) 13/25 (52%) of moms had an ICC need identified

Next steps Restart ICC screening on a regular basis in provider’s practice Implement ICC screening on clinic-wide basis and track data Assess clinical outcomes and develop interventions

Discussion Any comments or questions? Anyone here working on ICC in their health center? If so, how is it going? Specifically any comments on how you have integrated such specific screening into your EHR? It would be great to hear what other residency programs are doing for interconception care, if anything, as well as to hear if other health centers have found ways to make the electronic medical record work for such specific screening needs.

Bibliography Brown & Eisenberg. Best of Intentions. National Academy Press: Washington, D.C., 1995. CDC 2006 report - Unintended Pregnancy Prevention - Reproductive Health http://www.cdc.gov/reproductivehealth/unintendedpregnancy/ date accessed: 4/16/2012 CDC –Tobacco Use in Pregnancy. http://www.cdc.gov/reproductivehealth/tobaccousepregnancy/ accessed 4/21/2013. Conde­-Agudelo A, José M Belizán. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ 2000;321:1255–9 Conde-Agudelo, et al. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295: 1809-23. Downs DS et al. Design of the Central Pennsylvania Women's Health Study (CePAWHS) strong healthy women intervention: improving preconceptional health. 2009 Jan;13(1):18-28. Epub 2008 Feb 13. Effects and safety of periconceptional folate supplementation for preventing birth defects. De-Regil LM, Fernández-Gaxiola AC, Dowswell T, Peña-Rosas JP. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD007950. Review. Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. The Cochrane Database for Systematic Reviews. Volume (3), 2004. Orr, et al. Unintended pregnancy and preterm birth. Paediatric and Perinatal Epidemiology 2000; 14: 309-313. Villar, J., Merialdi, M., Gulmezoglu, A. M., Abalos, E., Carroli, G., Kulier, R. & de Onis, M. (2003) Nutritional interventions during pregnancy for the prevention or treatment of maternal morbidity and preterm delivery. An overview of randomized controlled trials. J. Nutr. 133: 1606S–1625S.