1. CRPN Perinatal Depression Project
Avril S Albaugh, MSSA
Project Director, Cleveland Regional Perinatal Network
Adjunct Assistant Professor, Psychiatry
Case Western Reserve University School of Medicine
Copyright 2018
Note: The slides and information in this presentation are proprietary;
the written permission of the Cleveland Regional Perinatal Network is required to make any changes to material

2. Mission
CRPN is the leader in mounting a broad community response to issues surrounding maternal, child and adolescent mental health. We drive change through programs designed to educate, train, and build awareness. We link providers to necessary resources and connect women, children and adolescents to valuable community services.

3. Funding/Support Grant Funding
Ohio Department of Health, Bureau of Maternal Child Health
This work is funded in whole or in part by the grant awarded by the Ohio Department of Health, Bureau of Maternal, Child and Family Health, Maternal and Child Health Program, and as a sub- award of the grant issued by Health Resources and Services Administration (HRSA) under the Maternal and Child Health Block Grant grant award number B04MC26688, and CFDA number and Am. Sub. H.B> 64
MomsFirst, a City of Cleveland Department of Public Health Program
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H49MC00082 Eliminating Disparities in Perinatal Health for $1,421,155 and 0% financed with nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Alcohol Drug Addiction Mental Health Services Board of Cuyahoga County
Woodruff Foundation
Fiscal Administration and in-kind Support
University Hospitals Case Medical Center

4. Outline Definition/background/history
Project development and infrastructure building
Establishment of a data tracking system
Project outcomes and evaluation of the CRPN’s Training Model and Screening and Referral Process
Perinatal Depression
Overview of Perinatal Mood Disorders
Impact of untreated depression on pregnancy outcome
Screening/Identification/Referral
Gaps/Barriers to seeking Mental Health Care Research Project
Centering Pregnancy/Mental Health Project

5. Project Infrastructure
Cleveland Regional Perinatal Network
Project Director
Program Coordinator
Program Specialist
Perinatal Depression Project
UMWH Centering Pregnancy
Mental Health Project
Child & Adolescent
Mental Health Project

6. CRPN Perinatal Depression Project 2005 - 2017 A Model of Evidence Based Practice
Developed an effective strategy to identify perinatal depression and enhance access to mental health services in Northeast Ohio.
Created a system-wide approach to screen and refer women at risk by establishing universal screening and referral protocols at several health care institutions and community agencies in the Cleveland area.
Collaborates with major stakeholders within the behavioral and healthcare communities in the region.
Evaluated by Case MPH candidate in % provider satisfaction rate after implementing protocols.
Relevant impact on local, state-wide and national levels of public health including project duplication in other counties.

7. Background and History

8. Perinatal Depression: Defining the Problem in Cuyahoga County, Ohio in 2002

9. 2002 Project Goals
A. Estimate occurrence of perinatal depression in African –American women, aged 15 to 44, residing in city of Cleveland
B. Identify screening and referral practices among health care and social service providers
C. Identify mental heath services for women with perinatal depression
D. Make recommendations
A. 386 participants: 248 prenatal, 138 postpartum. Using EPDS Cut off Score 13 +, 19% (72 of 386) screened at risk for perinatal depression. Prenatal 21%
Postpartum 14%.
B. No provider using tool. Screening inconsistent.
B. No provider at time using formal screening tool. Screening inconsistent.
C. No mental health agency with perinatal program.
D. Convened focus group to assist with recommendations 9

10. Population Sample
Cleveland Healthy Family Healthy Start Perinatal Depression Project. Feelings of African American Women: 2002

11. Cleveland Healthy Family Healthy Start Perinatal Depression Project
Cleveland Healthy Family Healthy Start Perinatal Depression Project. Feelings of African American Women: 2002

12. Method Edinburgh Postnatal Depression Scale with cut off score 13 +
Cleveland Healthy Family Healthy Start Perinatal Depression Project. Feelings of African American Women: 2002

13. Results : Occurrence 23% = subsample of women with missed appointments
Cleveland Healthy Family Healthy Start Perinatal Depression Project. Feelings of African American Women: 2002

14. Results Screening and Referral Practices Mental Health Services
29 healthcare and social service agencies surveyed:
Provider screening inconsistent and only 1 using a screening tool
Mental Health Services
Telephone surveys of 79 mental health agencies:
Half would see women experiencing perinatal depression
No agency contacted had specific program for perinatal depression (2002)
Survey completed by United Way First Call for Help: 2002

15. Convene Provider Focus Group and Present Findings
Focus Group Questions
What do you think of current system of services for perinatal depression?
What do you see as gaps and barriers?
What improvements would you
recommend?

16. 2002 Focus Group Findings: Comments Regarding System
No Continuity
Fragmented
Confusing
Complex
Impersonal
What System?
Finding the right person to speak with could be difficult. Voic often only option. Rarely hear back what happened to client. Referrals made to mental health agencies who were not able to offer services. Wait time for appointment average 2-3 months.
Cleveland Healthy Family Healthy Start Perinatal Depression Project. Feelings of African American Women: 2002 16

17. 2002 Focus Group Findings: Provider Gaps and Barriers
Reluctance to screen
Inconsistent screening
Knowledge of resources
Lack of perinatal mental health services
Poor referral mechanism
Wait time for appointments months
No follow up
Lack of integration between systems
Reluctance to screen: Providers said: none of my business, would’t know what to do if I found it.
While history puts more at risk, cant always tell by looking
Inconsistent: no formal screening tool, no institution/agency mandating it
Lack of specific services: Who out there would see this population
Poor referral mechanism: Reaching voic not sure if referral was made, if client was contacted or seen
No follow up: Rarely heard back what happened to client
Cleveland Healthy Family Healthy Start Perinatal Depression Project. Feelings of African American Women: 2002 17

18. 2002 Focus Group Findings: Client Gaps and Barriers
Stigma/ Labeling Cultural Issues Mistrust of system Fear of Children & Family Services involvement Concerns with taking medications while pregnant Lack of information about depressive symptoms and treatment Mental health in separate setting, issues with transportation, child care and 2-3 month wait time for intake apt
Stigma little different than general stigma of mental health because of pregnancy. Happy joyful time but mom knows sometime’s not jiving. A lot of discomfort sharing this with her provider.
Mom feeling that she was being labeled “crazy” and perinatal depression being lumped in with more severe diagnosis psychosis etc.
Cultural Issues: Some cultures don’t believe in sharing with outsiders keep it in the family
Mistrust of system: What are you going to do with this information
Mental Health Agency separate setting: Shame and discomfort going for appointments
Transportation: agency not on a bus route; takes a lot of energy when you are depressed and pregnant and to get to your appointments
Childcare: should be on there.
Wait time: Huge Challenge: Wait time for call back to set appointment, wait time until appointment , office wait time.
Cleveland Healthy Family Healthy Start Perinatal Depression Project. Feelings of African American Women: 2002 18

19. Gaps to be Spanned Lack of provider screening and referral
Little knowledge of appropriate MHS
Client difficulty accessing MHS
No follow up information
Need for public awareness
Realized huge gaps to be spanned: 19

20. Project Development and Infrastructure Building

21. How Did We Begin to Address the Issues?
Reframing the concept of perinatal depression as a public health concern.
Advocating that screening should be incorporated into clinical practice as a standard of care.
Promoting universal screening which helps to reduce the stigma.
Asking the right questions opens doors and encourages women to disclose their feelings.

22. CRPN Materials for Raising Awareness
Child-Adolescent Resource Card
Maternal Depression
Resource Card
Guide For Moms
Maternal Depression Poster
Child-Adolescent Tablet
Maternal Depression Tablet

23. Bridge Gap Between Screening and Mental Health Providers
Identification
Access
Services
Education
Follow Up
We needed to focus on bridging the gap between the Referring providers and mental health providers:
Educate referring providers to screen and identify the problem
Improve access to services by working with mental health providers to address the referral and intake process so clients can receive appointments quickly
Establish an effective feedback system between providers for the follow up 23

24. Identification: Screening and Referral
2005 Child and Family Health Services Block Grant to provide on site training free for all providers in Cuyahoga County and the region.
Developed agency specific care paths utilizing formal depression screening tool, EPDS
Created network of Perinatal Mental
Health Providers (PMHP)
CRPN website updated :

25. Screening and Referral Process
What does the Care Path do?
How to screen
When to screen
What if score is elevated
What if suicide item is checked
How to make referral
What referral is appropriate
What if client refuses
How to get follow up information

27. Health Care Community Agencies Out of County HMO’s
CRPN Perinatal Depression Project
Protocol Sites *
Health Care
UHCMC (OB & Peds)
Rainbow Care Connection
Cleveland Clinic Regional Health
(Fairview, Hillcrest)
MetroHealth Medical Center
SouthWest General Hospital
NEON
Community
Agencies
CCDCFS
PEP/ECMH
Applewood Centers, Inc
Beachbrook
OhioGuidestone
Out of County
Summit County Maternal
Depression Network
Lorain Maternal Mental
Health Task Force
Home Visiting
City Of Cleveland, MomsFirst
Cuyahoga HMG Bright Beginnings
Cuyahoga Board of Health,
Newborn Home Visits
HMO’s
CareSource
* Sites which have received training and following agency-specific carepaths developed by CRPN Project Director 27

28. Improvements in Provider Linkages
2005 convened Cuyahoga Perinatal Depression Task Force consisting of multi- agency providers:
Purpose: Address problems with identification, current referral and intake system and make improvements. Meets quarterly.
Health Care – UHCMC, MetroHealth, Cleveland Clinic/NEON
Home Visiting – MomsFirst/Help Me Grow, Cuyahoga Board of Health/VNA
Mental Health - Cuyahoga Mental Health & Addiction Board/Perinatal Mental Health Agencies/Psychiatrists/Frontline Mobile Crises
Social Service – Cuyahoga Department of Children & Family Services/Domestic Violence Center
Medicaid Managed Care Providers –CareSource/United Health/Promedica/Molina/Bucheye
Other Counties – project duplication

29. Difficulty Accessing Services
What is wrong with current referral and intake and how can we make it better????

35. Establishing A Data Tracking System Providing Care Coordination

36. Data Collection
Monthly – Applewood, Bellefaire, Connections, Far West Center, OhioGuidestone
Quarterly - MetroHealth, Cleveland Clinic, CCBH/NHV, MomsFirst, Bright Beginnings

39. Measuring Project Outcomes

40. POP QUIZ
What percentage of women living in Cuyahoga County referred for mental health services actually made their intake appointment in 2012?
8 %
12 %
38 %
57 %
85 %

51. 2016 Impact of EPDS Screening Efforts
•14,748 BIRTHS IN CUYAHOGA COUNTY
•13,408 SCREENINGS WERE COMPLETED FOR PERINATAL / POSTPARTUM DEPRESSION (AN AVERAGE OF MORE THAN 36 SCREENINGS PER DAY, EVERY DAY!)
•1,284 WOMEN WERE REFERRED TO ONE OF OUR FIVE MENTAL HEALTH AGENCIES (AN AVERAGE OF MORE THAN 3 WOMEN PER DAY, EVERY DAY!)
•478 WOMEN RECEIVED TREATMENT FOR THEIR DEPRESSION
(AN AVERAGE OF MORE THAN 1 WOMAN PER DAY, EVERY DAY!)

52. State-Wide and National Implications
Ohio
CRPN Model incorporated into ODH Maternal Child Health block grant application process since 2016.
Project Duplication in other Counties
National
Participated in workgroup on Intimate Partner Violence & Perinatal
Depression convened by HRSA/MCHB in Washington DC 2011.
CRPN Carepath and other resources included in 2013 national toolkit for Healthy Start providers.
Urban Institute research study Home Visiting and Maternal Depression. Referenced as promising model for the rest of the Country”.
August 2007, CRPN Perinatal Depression Project won the Most Innovative Practice Award at the National CityMatch Convention.

53. by Erica N Chambers MPH Candidate, Case Western Reserve University
2012 Study
The CRPN Perinatal Depression Project: An Evaluation of the Training Model and Screening and Referral Process
by Erica N Chambers MPH Candidate, Case Western Reserve University

54. Purpose
Goal: Used concurrent mixed methods study to evaluate the perinatal depression provider training model created by the CRPN Perinatal Depression Project and the screening and referring process among healthcare and community based institutions.
Objectives:
Assess the satisfaction with the training and education among community and healthcare institutions have received from the PDP.
Assess the usefulness of implementing the perinatal depression carepath protocol, tools, and resources.
Identify the variables that contribute to barriers and successful screening and referral practices among referring providers. 54 54

55. Methods Setting/Sample
Healthcare and community settings that implemented Carepath protocol and trained by the PDP in the last 2-3 years. Included both suburban and inner city settings.
Non-random; 6 healthcare and community based institutions were contacted and a population sample of healthcare and community based administrators and providers were included.
Some institutions had multiple sites.
Instrument
Interview Guide
12 item survey, open ended text, completed by providers.
Conducted 30 minute semi-structured, in-depth interviews.
Approved by Case Behavioral/Social Science IRB.
Urban and suburban setting offering social and healthcare services to a diverse group of women. 55 55

56. 4 of 6 Institutions participated : 67% response rate
Results
Quantitative Analysis
4 of 6 Institutions participated : 67% response rate
On the next following slides what I have compiled are the results from the instrument that was administered to theses providers. Each chart addresses my initial research questions and the metrics used to glean information to answer that research question along with the responses. 56 56

57. Summary and Conclusions
Majority of the participants from this study (92.8%):
Thought that the Project was meeting it’s goal and were satisfied with the Carepath protocol in helping them to stream-line the screening and referral process.
Were pleased with the resources, education, and tools received from the PDP.
Felt that due to help from the PDP Project Coordinator, implementation of Carepath protocol and use of tools done without many complications.
Feedback about the Project and Goals (Qualitative Analysis) :
“Did an excellent job.”
“Far exceeded my expectations, very well done…so much momentum and it’s become widespread, more acceptable, and the providers feel a responsibility to do it.”

58. Enhancing the Mental Health and Wellbeing of Centering Pregnancy Patients
Pilot Project 2/1/2015 – 1/31/2016
Funding support provided by March of Dimes Community Grant.

59. What is CenteringPregnancy®?
CenteringPregnancy is a model of prenatal care that:
Integrates health assessment, education and support in a dynamic group setting
Targets African-American women ages from low-income areas in Cuyahoga County, a group at risk for adverse birth incomes

60. What is CenteringPregnancy, con’t
Patients are placed in groups of 8-12 women with similar gestational ages
Participants receive a health assessment by a licensed health care provider
Women learn care skills and participate in facilitated discussion
Strong support networks are developed

61. Collaborative effort involving CRPN, UMWH/Centering Pregnancy, OhioGuidestone and MomsFirst Project.
Increase identification of maternal mental health concerns
Improve care coordination
Expand access to community mental health services
Provision onsite mental health services by OhioGuidestone
Incorporate stress reduction techniques into CP curriculum
Offer MomsFirst referral to all CP patients
To reduce infant mortality, CRPN & UHMWH are collaborating partners with Ohio’s Equity Institute, which identified Centering Pregnancy as a downstream strategy.

62. Centering and OhioGuidestone Collaboration 2015
OG - Mental Health Counselors have attended all Sessions 2 & 4 since February All Sessions 8 since August 2015
Goals:
Reduce stigma, build trust and increase engagement by accepting referral for mental health services.
Assist Centering staff deal with sensitive psychosocial issues.
Participation involves entire group session offering tools and tips to deal with stress and emotional issues in pregnancy.

63. Outcomes – Data 2/1/2015 – 1/31/2016 252 total women enrolled
At sessions 2,4, 8 EPDS screens completed 367 times
13 women not screened (prior to training mid Feb; poor prenatal care; late pnc)
95.6% screening rate
63 positive EPDS scores (at risk – 12 and above)
5 declined referral
11 already receiving mental health services
69 referrals accepted to OhioGuidestone
22 more women accepted onsite mental health referral than scored at risk on the EPDS

64. Outcomes – Most Significant Impact
Of the 69 referrals accepted by CenteringPregnancy patients, 22 (32%) of those had a negative EPDS score, indicating that 32% of patients were identified because of the presence of an onsite mental health counselor

65. Outcomes – Feedback from Centering Pregnancy Staff
During groups sessions:
OhioGuidestone Mental Health Counselors (OG/MHC) are able to provide more resources and information for patients.
Patients feel more comfortable and more willing to accept an OG mental health referral because they can “connect to a face” in the group, building up trust and are more willing to talk with the MHC.

66. Outcomes – Feedback from Centering Pregnancy Staff, con’t
MHC presence supports staff discussing sensitive and potentially explosive topics.
MHC is skilled in interpreting and reframing underlying messages to assist patients in dealing with their problems in a more positive way.
Fathers seem to also benefit from the discussion and able to identify practical stress management techniques.
MHC presence provides a structured conversation on suggestions to manage interpersonal conflict for couples.

67. Outcomes – Feedback from Centering Pregnancy Staff, con’t
Some patients’ Edinburgh scores have declined over the course of group sessions.
MHC presence has helped to reduce stigma and encouraged patients to accept referral later after initially declining.

68. Continuation grant funding provided by Woodruff Foundation for years 2 & 3
data collection

72. 35%
65%