1. 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 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