1. Perinatal Depression: Bridge to Community Treatment CityMatCH August 28, 2007 Marilyn Benjamin, MSN, RN Project Director, Cleveland Regional Perinatal Network

2. Outline  Background  HFHS Project Findings  Focus Group  Gaps and Barriers  Strategies  Future Issues

3. Cleveland Regional Perinatal Network (CRPN)  Funded by Ohio Dept of Health, Bureau of Child and Family Health Services, Regional Perinatal Center Program  Grant to University Hospitals Case Medical Center in collaboration with MetroHealth Medical Center.  Assist coordination of regional system of perinatal resources, facilitate hospital- community agency linkages  Focus on data use to identify needs and to improve services/outcomes.

4. Cleveland Healthy Family/Healthy Start Perinatal Depression Project  Responded to RFP from City of Cleveland Dept of Public Health, Healthy Family/Healthy Start  Six month project 2002 “Feelings of African American Perinatal Patients”

6. 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

7. Results: Occurrence  386 participants 248 prenatal, 138 postpartum  313 in person, 73 by phone  Using EPDS* Score 13 +, 19% (72 of 386) screened at risk for perinatal depression *Edinburgh Postnatal Depression Scale

8. Edinburgh  Simple to complete  Acceptable to mothers and providers  10 questions  In public domain  It is screening tool, not clinical diagnostic instrument

9. Results: Occurrence Screened at risk  Prenatal 21%  Postpartum 14%  Telephone respondents 23%  In person 18% As # pregnancies increased, risk increased

10. Results: Occurrence Receiving services  2% said they were receiving mental health services  6% admitted to history of mental illness

11. Results: Agency Screening and Referral Practices  Telephone surveys of 29 healthcare and social service agencies  28 used no formal screening tool consistently

12. Results: Perinatal Mental Health Services Telephone surveys of 79 mental health agencies (First Call for Help)  Half would see women experiencing perinatal depression  No agency contacted had specific program for perinatal depression(2002)

13. Perinatal Mental Health Services  Finding the right person to speak with could be difficult.  Information provided depends on who is contacted.  Agencies sometimes made referrals to other agencies who were not able to offer services.

14. Risk of serious disorder prevalent in pregnancy and post partum with negative consequences for women and their infants Gaps in identification Gaps in access to care Gaps in services

15. Findings Presented Get your facts first, And then you can distort them as much as you please.Mark Twain  Focus Group OB/Ped, Mental Health Care Providers  Insurance Summit Medicaid, Managed Care Mental Health Board

16. 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?

17. Comments regarding system  No Continuity  Fragmented  Confusing  Complex  Impersonal  What System?

18. Barriers:  Provider reluctance to screen  Inconsistent screening  Knowledge of resources  Lack of specific services  Poor referral mechanism  No follow up for referral  Lack of parity for mental health  Lack of integration between systems

19. Barriers: Provider  Reluctance to screen Can’t tell by looking History puts more at risk but can’t tell just by history Didn’t think it was their business Didn’t know what to do if they did make it their business

20. Barriers: Client  Stigma/ Labeling  Cultural Issues  Mistrust of system  Fear of involving children’s services  Fear of medications  Depression itself  Mental health in separate setting  Transportation  Wait time  Lack of public information about symptoms and treatment

21. Gaps  Lack of screening and referral  Lack of knowledge of appropriate services  Difficulty accessing community services  Lack of follow up information after referral  Lack of public awareness

22. Bridge to Community Treatment

23. Identification: Screening and Referral  Grants to provide on site training free for all providers in Cuyahoga County and the region.  Assistance with developing agency specific care paths utilizing formal depression screening tool.  Ohio Dept of Health Help Me Grow pilot sites utilizing training model

24. Overcoming resistance to screen  Group process to listen and address provider concerns  Reframe the concept of perinatal depression as a public health concern  Screening should be standard of care  Asking the right questions opens doors and encourages women to disclose their feelings

25. Overcoming resistance to screen  Need for Care Path 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

26. Knowledge of services  Resource list for providers and consumers Original version produced in association with MomsFirst and Dr. Amy Heneghan Case Western Reserve University. Reproduced in state version by Ohio Department of Mental Health. Also in Spanish.

28. Mental Health Services Educated ourselves regarding existing services for maternal depression Visited mental health providers Found out what services available Looked at intake process Told them provider issues Listened to their issues Asked what we could do to help

29. Access and Follow Up Formed Perinatal Depression Referral and Intake Task Force Perinatal HealthCare Providers Mental HealthCare Providers Mental Health Board Currently 29 members, 16 agencies

30. Difficulty accessing services What is wrong with current referral and intake and how can we make it better????

31. Difficulty accessing services HC Provider issues: Voice mail/ Call back No info back Unfamiliar with services MHC Provider issues: Unable to reach provider or client Insufficient information No shows

33. Fax Referral Form  Sufficient client info  Permission to exchange info  Participating MH Providers listed Added location, services, limitations  Part of provider training  Part of care paths  Pilot sites to measure effectiveness

34. Public Education Handout and Poster

36. Future issues  Screening part of routine care  Central Intake  No show rate for appointments  Access: transportation, on site services, alternative care delivery sites  Assessments in the home  Medicaid Managed Care  Outcome Data

37. Perinatal Depression Project Funding  The Ohio Department of Health, Bureau of Child and Family Health Services  Regional Perinatal Center Program and  Cuyahoga County Child and Family Health Services  City of Cleveland, Department of Public Health, MomsFirst Project, supported in part by the Healthy Start Initiative, Division of Perinatal Systems and Women’s Health, Maternal and Child Bureau, Health Resources and Services Administration, U.S.Department of Health and Human Services.

38. Contact Information Marilyn.Benjamin@uhhospitals.org 11001 Cedar Ave., Suite 320 B Cleveland, OH 44106 216-844-3391 www.crpn.net

39. Discussion