1. 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

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

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

11. 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

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

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

14. Display toolbox
Display toolbox

15. Each Mom leaves with a “prescription” for THEM

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

17. 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

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