1. Reinventing Healthy Start
Michael C. Lu, MD, MPH
Associate Administrator
Maternal and Child Health Bureau
Health Resources and Services Administration
Secretary’s Advisory Committee on Infant Mortality
Bethesda, MD
July 10, 2012

2. Why Reinvent Healthy Start?

3. Why Reinvent Healthy Start?
New Science
New Opportunities
Same Old Gap

4. Fetal Origins of Health & Disease
The life course perspective has two major components: an early programming component, and a cumulative pathways component.
The early programming model posits that experiences early in life can influence health and functions later in life. This model grew out of the Barker hypothesis and has grown into a large body of research collectively known as developmental origins of health and disease. Key concepts include timing – timing matters; what happens during sensitive and critical periods matters; and trajectory – whether you start off like this, or like this, can determine your health trajectory over the life course.
Now I want to remind you that this is not a deterministic model, as some has suggested. Undernutrition in the second trimester doesn’t mean that your baby is doomed to get diabetes or kidney disease, but it could affect the number of beta cells in her pancreas or nephrons in her kidneys. It doesn’t predict disease outcomes, but it does define capacity, it does limit potential
The cumulative pathways model is about accumulation of risks and insults, irrespective of timing, that can cause a decline in health and functions over time. It came out of life course chronic disease epidemiology. Key concepts include weathering (and more recently, allostatic load which is the physiological toll of weathering) and pathway – which refers to the idea that these risks and insults don’t just occur randomly; they tend to cluster in a socially patterned way e.g low childhood SES is associated with poor growth, more family stress, and inadequate diet, all of which cluster to create a pathway leading to earlier menopause 4

5. Racial and Ethnic Disparities in Birth Outcomes: A Life Course Perspective
This may be particularly important for perinatal health, where we focus so much on events occurring in the 9 months of pregnancy we forget that there are a great deal of life course influences on perinatal outcomes, and a great deal of perinatal influences on life course outcomes.
For example, in explaining the Black-White gap in infant mortality, for decades we searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health interventions and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country.
Many of us recognize now that to expect prenatal care, in less than nine months, to reverse all the cumulative disadvantages and inequities over the life course of the woman, may be expecting too much of prenatal care. If we as are serious as a nation about improving birth outcomes and reducing disparities, we have to start taking care of women not only during pregnancy, but before pregnancy and between pregnancies and indeed, across their entire life course.
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30. 5

6. New Opportunities Patient Protection and Affordable Care Act
Bans denial of coverage based on preexisting conditions
Bans lifetime limits on benefits
Extends dependent coverage until age 26
Expansion of medicaid eligibility
Expansion of community health centers
Expansion of school health centers
Expands coverage for clinical preventive services for women including preconception and interconception care
The ACA has done a lot to expand healthcare coverage, but as all of you know, coverage is only half of the story. There are important issues that have to be addressed around access, content and quality, and organization and delivery of services. Improving access to poor quality, highly fragmented services is no real healthcare reform. 6

7. Same Old Gap
The racial gap has persisted.
Data Source: NCHS

8. You don’t get a fair shot if you can’t get a healthy start.
So let me conclude my part with a few of my favorite quotes 8 8

9. The definition of insanity is doing the same thing over and over and expecting different results.
Benjamin Franklin
So let me conclude my part with a few of my favorite quotes 9 9

10. Healthy Start 3.0

11. Healthy Start 1.0 1991-1997 Outreach and case management
Support services and health education
Enhancement to clinical services
Consortia development
Management Information Systems
Public information campaigns
Infant mortality reviews

12. Healthy Start 2.0 (1996-2012) Outreach Case management
Health education
Screening & referral for maternal depression
Interconceptional care
Community consortia
Local health action plan
Collaboration & coordination with Title V services
Sustainability

13. Healthy Start 3.0 Assure access Promote resilience Improve quality
Enhance system integration
Drive community transformation

14. Healthy Start 3.0 Assure access Promote resilience Improve quality
Enhance system integration
Drive community transformation

15. Assure Access Assure access to healthcare across life-course continuum
Coverage = Access
Outreach and care coordination
Translation and transportation
Cultural and linguistic competency
Community engagement and trust
Healthy Start provides ACA with ready-made infrastructure to increase healthcare access

16. Healthy Start as Gateway to Healthcare

17. Healthy Start 3.0 Assure access Promote resilience Improve quality
Enhance system integration
Drive community transformation

18. Resilience
Bruce McEwen uses this diagram to illustrate allostatic load. The lower image is an image of allostasis – maintaining stability through change. The upper image is one of allostatic load – if you put kilo sumo wrestlers on a seesaw what is going to happen? It is going to break.
McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002

19. Allostasis: Maintain Stability through Change
But what happens after you got away? Your heart rate slows down, your blood pressure comes down, and you body calms down. The amazing thing about the human body is that it is self-regulating; it knows to shut itself off once the stressor has been removed. This is called allostasis – maintaining stability through change.
Allostasis works by a negative feedback mechanism, which is found common to many biological systems. It works very much like a thermostat. When the temperature falls below a preset point, it turns on the heat. Once the temperature reaches that preset point, the heat is turned off. In the stress response, the HPA axis produces cortisol. Cortisol, in turn, feeds back to the brain to shut off the HPA axis.
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

20. Promote Resilience Promote positive coping skills Relaxation exercises
Mindfulness
Transcendental meditation
Positive psychology
Promote financial literacy
Promote interpersonal communication
Promote parenting skills
Promote father involvement
Faith and social capital as sources of community resilience

21. Healthy Start as Cradle of Resilience

22. Healthy Start 3.0 Assure access Promote resilience Improve quality
Enhance system integration
Drive community transformation

23. Ohio Perinatal Quality Collaborative
In 22 states, Medicaid already covers components of pre- and interconception care through their 1115 family planning demonstration which can now be converted to a state option, but such coverage is limited. For example, it wouldn’t cover treatment of diabetes uncovered during the family planning visit.
What Medicaid can do is to expand Medicaid benchmark benefits to include “well-woman” benefit, comprehensive pre- and interconception care, with provisions that override limitations and exclusions based on preexisting conditions.
Donovan EF, Lannon C, Bailit J, Rose B, Iams JD, Byczkowski T; Ohio Perinatal Quality Collaborative Writing Committee. A statewide
initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation.Am J Obstet Gynecol Mar;202(3):243.e1-8. 23

24. Improve Quality Quality gaps Take QI from bedside to curbside
Not only hospital systems QI, but community systems QI

25. Healthy Start as Driver of Quality Improvement

26. Healthy Start 3.0 Assure access Promote resilience Improve quality
Enhance system integration
Drive community transformation

27. Enhance Systems Integration
Vertical integration
Appropriate levels of care
Horizontal integration
Systems navigation & integration
Longitudinal integration
Care continuum across the life course
The ACA has done a lot to expand healthcare coverage, but as all of you know, coverage is only half of the story. There are important issues that have to be addressed around access, content and quality, and organization and delivery of services. Improving access to poor quality, highly fragmented services is no real healthcare reform. 27

28. Prenatal Care 1.0
Receptionist
& Clerks
Medical
Assistant OB
Nurse Manager
Ultrasound
Tech
This is what you are currently paying for, what I call the 1.0 system of prenatal care. You are paying OBs in solo or small group practice who don’t have much time or resources for health promotion and care coordination. Does this look like quality healthcare to you? Probably not. Especially given what we know today about the importance of nutrition, mental health, and environmental toxicology to fetal programming, how much health education/health promotion on these topics do you think is going on in the ob office?
Lu MC. Healthcare reform and women’s health: A life-course perspective.
Curr Opin Obstet Gynecol 2010;22:487-91 28

29. OB Prenatal Care 2.0 High Risk OB Primary & WIC Specialty Care
Receptionist
Medical
Assistant OB
Teratogen
Information
Services
Social
Services
Nurse Manager
Ultrasound
Tech
To make up for the design flaws of the 1.0 system, over the past two decades public health has been trying to create these wrap-around services to enhance the quality of prenatal care. This is what Healthy Start, Nurse Family Partnership, and other public health programs have been paying for. The problem, of course, is that case management and care coordination in a fragmented, flawed system are very labor-intensive and costly, and so the caseload for each program has to be small, and the population health impact of these programs is necessarily limited.
Family
Support
Oral Health
Mental Health
Lu MC. 2010;22:487-91 29

30. Medical Home Prenatal Care 3.0 High Risk OB OB Dietitian Hospitalist
& WIC
Health
Education
Prenatal
Care
Preconception &
Interconception
Care
Medical
Home
Ultrasound
Center
Mental
Health
Primary &
Preventive
Services
Family Support
& Social Services
We need a new delivery system for prenatal care, moving it the current 1.0 or 2.0 system to the 3.0 system, with greater vertical, horizontal, and longitudinal systems integration. In this 3.0 system of prenatal care, the OB office is no longer the center of universe, but rather it’s the medical home for women’s health, complete with health education (including counseling about nutrition, stress and mental health, and environmental exposures), family planning, family support and social services, and primary and preventive care. This medical home for women’s health is designed to deliver not only prenatal care but also pre- and inter-conception care, indeed, comprehensive women’s health services across the life course continuum. Care coordination and service integration are enhanced by a “micro-navigator” (case worker, community health worker or community health team) and a strong backbone of HIT that supports data systems integration.
Family
Planning
Oral
Health
Genetic Counseling
& Prenatal Diagnosis
Specialty Clinics
Lu MC. 2010;22:487-91 30

31. Healthy Start Shared Resource ` OB OB Health Education OB OB Nutrition
Counseling
Quality
Improvement
Healthy
Start
Systems
Navigation
Family Support
& Social Services OB OB
Home
Visiting OB OB 31

32. Healthy Start as Systems Navigator, Integrator, and Shared Resource

33. Healthy Start 3.0 Assure access Promote resilience Improve quality
Enhance system integration
Drive community transformation

34. Healthy Start Community Development Economic Development Health
Educational
Development
We know it’ll take more than simply improving healthcare quality and system. In many of these communities there are high drop-out rates, poverty rates, high rates of teen pregnancy and fatherlessness; so we’ll have to work on educational development and economic development and community development. We’ll have to take a place-based, systems approach to transform an entire community over 10 years. Or it might take a generation. 34

35. Place-Based, Systems Approach
Health system
A “medical home” for women’s health that offers pre- and interconception care, quality prenatal and intrapartum care, systems navigation and integration, and cost-control platform;
Educational system:
A “pipeline to success” that begins early with “baby college” and quality early childhood education, “promise academy” and youth development programs;
Economic system:
An “opportunity incubator” that combines macroeconomic policies (e.g. empowerment or enterprise zones) with capital development (e.g. microfinance), business incubation and job training, financial literacy and asset development for families, and high-functioning safety net programs; and
Community system:
A “healthy community” that promotes environmental justice, healthy foods and physical activities, strong fatherhood and families, and racial equity.

36. Healthy Start as Community Transformer

37. Reinventing Healthy Start