Project 3B: Reproductive, Maternal and Child Health – Logic Model 2018 Target Population: Men or women of reproductive age, pregnant women, mothers of children ages 0 – 3, and children ages 0 – 17. Who: Consumers Tribes Parents Teachers Public Health Community Based Organizations Primary Care Behavioral Health Hospitals Managed Care Orgs CPAA Inputs: Training/Technical Assistance Assistance with clinic workflows LARC training for providers Bright Futures Training EMHI Training Trauma Informed Care Training School Based Health Services technical assistance Population Health Management Connect with Pathways HUB systems to monitor the population. Financial Sustainability Activities are billable in a Value Based Contract Activities are woven into everyday workflows Activities: One Key Question or Reproductive Screenings are happening in primary care, reproductive health, substance use, and behavioral health settings LARC Training and Counseling Bright Futures or EMHI Screenings are provided Train practices, partners, and community organizations in Trauma Informed Practices Pilot school based health services Provide oral health education in home visiting Outcomes: Short Term Increase LARC access Increase well child visit rates Increase chlamydia screenings Improve immunization rates Reduce unnecessary ED visits Reduce pre-term births Long Term Reduce teen pregnancy Increase Birth Weights Reduce Chronic School Absenteeism Reduce deaths due to reported neglect Improve high school graduation rates Improve Kindergarten Readiness (6/6 domains) Goals: Reduce Adverse Childhood Experiences passed down to the next generation. Care is provided at the right time at the right place. Vision: “Childhood abuse, neglect and family dysfunction in our communities is reduced; children are raised in a healthy, safe environment. Our communities’ resilience to social trauma is strengthened. There are early intervention and prevention services which provide our communities with strong social-emotional, behavioral, and physical health care allowing children and adults to better manage adverse childhood experiences.” Cross Project Areas Care Integration Initial screenings for depression & anxiety in home visiting Telehealth for behavioral health Developmental screenings at well child visits Family planning for individuals with SUD diagnosis Maternal mental health screenings @ pediatric visit Developmental screenings at home visits will be shared w/ primary care Integrate family planning into multiple settings Transitional Care Identify children with special care needs Transition Coach who does home visit with adult could provide referrals for family NFP RNs see postpartum moms six weeks after they are released Nurse is assigned to every woman during pregnancy and after delivery Pathways HUB Train care coordinators about existing resources Flag children with special health care needs NFP makes referrals for pregnant and or parenting moms Include reproductive health and maternal child health in the Pathways assessment Identify kids w/ special needs Coordinate with NFP nurse to receive care and connection to services Make referrals to NFP for pregnant/parenting moms Opioid Response Distribute naloxone during home child visit Provide safe prescription disposal to increase child safety While parents are served at substance clinics, children could be treated for primary services Chronic Disease Ongoing case management provided in behavioral health Integrate routine follow up through home visiting Make connections for mothers after birth