1. Addressing Disparities in Perinatal Health Using a Collaborative Approach: The PCC Community Wellness Center’s Experience May 17, 2006 Mark Loafman, M.D., M.P.H. Andrea McGlynn, C.N.M., M.S.N. Chicago, IL

2. PCC Highest Areas of Patient Population

3. Austin Community Selected Demographic/Health Data * Chicago Department of Public Health – Chicago Health and Health Systems Project April 2006 2000 Census Data Percent of Population

4. Austin vs. Chicago Infant Mortality 2003 Austin vs. Chicago Selected Perinatal Indicators 2003 Rate/1000 Live BirthsPercentage Source: Chicago Department of Public Health – Chicago Health and Health Systems Project April 2006

5. Overview of PCC History and mission History and mission Full-service community health center since 1993 Full-service community health center since 1993 330 funding (FQHC) since 2002 330 funding (FQHC) since 2002 Model of care Model of care Family Medicine Family Medicine 9 of 18 Attendings with MCH/OB Fellowship 9 of 18 Attendings with MCH/OB Fellowship Peds, OB/GYN, CNMs, FNPs, LCSWs, Psych Peds, OB/GYN, CNMs, FNPs, LCSWs, Psych Health education and outreach Health education and outreach Hosts MCH Fellowship and FM Residents Hosts MCH Fellowship and FM Residents Experience with health disparities collaboratives Experience with health disparities collaboratives

6. PCC UDS Data Year Total Users Prenatal Users Deliveries % LBW % Late Entry to Care HIV+ Prenatal Users 200211,35973744515%8%0 200320,92885864715%20%1 200422,65317791083 (836 PN users) 8%44%2 200525,23520861395 (1064 PN users) 9.7%42%3

7. Care Model Informed, activated Patient Prepared, proactive practice team Functional and Clinical Outcomes Health System Health Care Organization Self- management support Delivery system design Decision support Clinical information systems Community Resources and Policies ProductiveInteractions Source: Institute for Healthcare Improvement

8. Impact Analysis of PCC’s Model *Austin area, 1999. Source: I-PLAN data system **RSWH deliveries of PCC and unattached patients, 6-11/2004 Source: Perinatal database. FAMILY PRACTICE MODEL WITH OBSTETRICS Low birthweight (140/1,000 live births)* Very low birthweight (39/1,000 live births)* Low birthweight (101/1,000 live births)** Very low birthweight (9/1,000 live births)** Family Practice Residency MCH Fellowship Case Management Community Nursing AmeriCorps Outreach Workers CLINICAL MODEL OutcomeCommunity Problem

9. Opportunities to positively influence MCH PCC and Partners Maternal preconception health Environment Genetic/familial life course Lifestyle/stressors/ stress response SES conditions & disparities Prenatal course Early and individualized risk assessment and care Concurrent & prospective care management Networks & collaborations Access to ongoing health care Educational & economic opportunities Environmental safety Psychological & spiritual support services Social & legal resources Perinatal Pilot Collaborative Seeing wider opportunities to respond to the problem Influences on MCH

10. Example: Ramp-up of PDSAs Outreach to patients Refined tracking form(follow-up needed) Patient given specific contact person for appt. (barriers to appointment) Algorithm to prompt care/red folders (more comprehensive approach) GDM screening at hospital OB triage Plan-Do-Study-Act Method of Making Changes  Identify opportunity, then champion the idea  PDSA changes (> 119 PDSAs in Perinatal Pilot at PCC)

11. Top 7 Changes At the Health Center Front-loaded care Front-loaded care Prenatal sessions for all FP providers Prenatal sessions for all FP providers Psychosocial and depression screening (PHQ) Psychosocial and depression screening (PHQ) Self-management goals Self-management goals Performance Improvement assistant (PIA) role Performance Improvement assistant (PIA) role At the Hospital “Red folders” algorithm/outreach to unattached patients “Red folders” algorithm/outreach to unattached patients Joint practice committee: pre-M&M quality assurance Joint practice committee: pre-M&M quality assurance

12. Perinatal PECS Data at PCC July 2005 to Present Process (as of 4/06)* HIV test (100%) HIV test (100%) Psychosocial risk assessment (83%) Psychosocial risk assessment (83%) Prenatal depression screening (78%) Prenatal depression screening (78%) SMG (50%) SMG (50%) Early GDM screening (80%) Early GDM screening (80%) Outcome (7/05 to 3/06)* Preterm labor (13%) Preterm labor (13%) Low birthweight (13%) Low birthweight (13%) Infant mortality (0) Infant mortality (0) CHALLENGES *at pilot site only – selected indicators

13. Performance Improvement Program Identified Needs Patient Satisfaction Finance Grants Support Services Clinical & Collaboratives Employee/ Provider Satisfaction. P.I. Team/Task Force

14. Communication and Systems Development How do you measure that? Existence of… Processes developed and “institutionalized” Processes developed and “institutionalized” Extend care management model into hospital Extend care management model into hospital Evidence-based practice tools – algorithms, protocols, drills Evidence-based practice tools – algorithms, protocols, drills Excerpt from PCC’s Perinatal Collaborative Aim Statement: “…implementation of a patient safety system that prepares the multidisciplinary PCC and WSMC teams for high-risk patient care (antepartum, intrapartum, and postpartum) and encourages self- reporting and identification of ‘near misses’ by November 2005 at PCC and WSMC Family Birthplace.” “…implementation of a patient safety system that prepares the multidisciplinary PCC and WSMC teams for high-risk patient care (antepartum, intrapartum, and postpartum) and encourages self- reporting and identification of ‘near misses’ by November 2005 at PCC and WSMC Family Birthplace.”

15. PCC Community Wellness Center/West Suburban Medical Center PCC Community Wellness Center Board of Directors CEO and President Chief Medical Officer Erie Ct Site Lake Site Austin Site Salud Site South OP Site WSMC Site Fellowship Training Integrative referral system Integrative service delivery initiative Integrative medical education WSMC Inpatient/outpatient diagnostics Formal Community Collaborations Circle Family Care Interfaith House Westside Health Authority West Side Health Collaborative Care Coalition WSMC (PHO) managed care WSMC Family practice residency Target Population Reach by Risk Reduction Outreach Yellow Brick Road (Women’s Sober Living Haymarket House (alcohol/substance abuse Infant Jesus Dental UIC Dental School Chicago Urban Ministries (counseling, housing) Bethel New Life (social services, housing)

16. Closing the Gap Programs in Chicago Health Resources and Services Administration (HRSA) Closing the Health Gap Initiative on Infant Mortality Maternal and Child Health Bureau (MCHB) Risk Reduction Pilot Bureau of Primary Health Care (BPHC) Perinatal and Patient Safety Pilot Health Disparities Collaborative State MCH agencies and other granteesPerinatal collaborative pilot sites, then all FQHCs Target population reached by risk reduction outreachTarget Population that accesses prenatal care

17. Still More Needed to Close the Gap …and address social, economic, environmental disparities Health Resources and Services Administration (HRSA) Closing the Health Gap Initiative on Infant Mortality Maternal and Child Health Bureau (MCHB) Risk Reduction Pilot Bureau of Primary Health Care (BPHC) Perinatal and Patient Safety Pilot Health Disparities Collaborative State MCH Agencies and Other GranteesFQHCs (perinatal collaborative pilot sites then all FQHCs State MCH Agencies and Other GranteesTarget Population that accesses prenatal care Unreached target population high-risk for infant mortality, only accesses emergency services

18. PCC’s Plans for Collaborative Spread To other PCC sites To other PCC sites Unattached population Unattached population Assist in spread to other FQHCs nationally Assist in spread to other FQHCs nationally

19. More Plans Research to Better Understand: Role of prenatal care in improving outcomes Role of prenatal care in improving outcomes Improved psychosocial screening and health Improved psychosocial screening and health Workforce development Workforce development Model replication Model replication Integration of Services WIC/Case management together with CHC services WIC/Case management together with CHC services Behavioral health Behavioral health Community-based agencies Community-based agencies