1. Integrating the Life Course Model into Case Management Services NORTHEAST FLORIDA HEALTHY START COALITION, INC. Presenters: Carol Brady, MA Faye Johnson, BS Faye Johnson, BS July 15, 2009 July 15, 2009

2. Snapshot of Jacksonville Infant mortality rate (2007): 9 deaths per 1,000 live births (2005 rate was 11.6) Infant mortality rate (2007): 9 deaths per 1,000 live births (2005 rate was 11.6) IM driven by disparities IM driven by disparities 42% of births to Blacks & other nonwhites 42% of births to Blacks & other nonwhites Blacks historically have poorer outcomes in Jax than other urban areas of state Blacks historically have poorer outcomes in Jax than other urban areas of state IM rate 2x higher than White rate IM rate 2x higher than White rate

3. The Magnolia Project Focus on disparities in birth outcomes Focus on disparities in birth outcomes Perinatal Periods of Risk (PPOR) Perinatal Periods of Risk (PPOR) Fetal & Infant Mortality Review (FIMR) Fetal & Infant Mortality Review (FIMR) Findings used to develop the Magnolia Project Findings used to develop the Magnolia Project Adaptation of state, federal Healthy Start models to address health of high-risk women before and between pregnancies Adaptation of state, federal Healthy Start models to address health of high-risk women before and between pregnancies

4. The Magnolia Project Benefits Benefits Addressed gap in women’s health care Addressed gap in women’s health care Linkage to national preconception health movement (CDC) Linkage to national preconception health movement (CDC) Promising practice, long-term impact on outcomes Promising practice, long-term impact on outcomes Limitations Limitations Still an INDIVIDUAL intervention Still an INDIVIDUAL intervention “Boom-a-rang” effect (dependency model?) “Boom-a-rang” effect (dependency model?)

5. Beyond Preconception National MCH Life Course meeting (2008) National MCH Life Course meeting (2008) Goal: to promote dissemination and use of life course approach to close black-white gap in birth outcomes Goal: to promote dissemination and use of life course approach to close black-white gap in birth outcomes Developed by Michael Lu, et al. Developed by Michael Lu, et al. Approach suggests a complex interplay of biological, behavioral, psychological and social protective factors contributes to health outcomes across the span of a person’s life. Approach suggests a complex interplay of biological, behavioral, psychological and social protective factors contributes to health outcomes across the span of a person’s life.

6. Life Course Perspective Rather than focusing on risks, behaviors & services during pregnancy, CUMULATIVE effects of health, life events are examined Rather than focusing on risks, behaviors & services during pregnancy, CUMULATIVE effects of health, life events are examined Health & socioeconomic status of one generation directly affects the health status --- and REPRODUCTIVE HEALTH CAPITAL – of the next one. Health & socioeconomic status of one generation directly affects the health status --- and REPRODUCTIVE HEALTH CAPITAL – of the next one.

7. Life Course Perspective Life-course model BROADENS the focus of MCH to include both health and social equity. Life-course model BROADENS the focus of MCH to include both health and social equity. Socioeconomic status, race and racism, health care, health status, stress, nutrition and weight, and a range of other behaviors impact birth outcomes. Socioeconomic status, race and racism, health care, health status, stress, nutrition and weight, and a range of other behaviors impact birth outcomes. Factors impact racial, ethnic groups differently and may explain disparities despite equal access to care during pregnancy. Factors impact racial, ethnic groups differently and may explain disparities despite equal access to care during pregnancy.

8. Life Course Perspective Life course framework in MCH has PROGRAMMATIC and POLICY implications. Life course framework in MCH has PROGRAMMATIC and POLICY implications. Content of case management is expanded (poverty, economic security, education) Content of case management is expanded (poverty, economic security, education) Services are organized and delivered in ways that build resiliency and social capital and reduce dependency (group activities, self-care) Services are organized and delivered in ways that build resiliency and social capital and reduce dependency (group activities, self-care) Requires inter-disciplinary, inter-agency collaboration to address complex needs Requires inter-disciplinary, inter-agency collaboration to address complex needs

9. Life Course Perspective Challenge: how to OPERATIONALIZE? Challenge: how to OPERATIONALIZE? Contra Costa Health Services: 12 point plan Contra Costa Health Services: 12 point plan Goals: Goals: Improve health care services for at-risk populations, including communities of color & low-income families Improve health care services for at-risk populations, including communities of color & low-income families Strengthen families & communities Strengthen families & communities Address social and economic inequities over the life course Address social and economic inequities over the life course

10. 12 Point Plan Improve Health Care Services Improve Health Care Services Access to interconception care, preconception care, quality prenatal care, access to health care Access to interconception care, preconception care, quality prenatal care, access to health care Strengthening Families & Communities Strengthening Families & Communities Father involvement, service coordination, creation of reproductive health capital, community building & urban renewal Father involvement, service coordination, creation of reproductive health capital, community building & urban renewal Address social, economic inequities Address social, economic inequities Close education gap, reduce poverty, undo racism support working mothers Close education gap, reduce poverty, undo racism support working mothers

11. Life Course Perspective Challenge: Challenge: How to OPERATIONALIZE life course approach into service delivery How to OPERATIONALIZE life course approach into service delivery Opportunity: Opportunity: Change the way we deliver case management services at the Magnolia Project Change the way we deliver case management services at the Magnolia Project Pilot project Pilot project

12. The Magnolia Project Case Management has Evolved Most case management models focus on specific individual risk factors. Most case management models focus on specific individual risk factors. Risk factors may include family planning, sexuality transmitted diseases, substance abuse, smoking, and other risk associated with poor birth outcomes. Risk factors may include family planning, sexuality transmitted diseases, substance abuse, smoking, and other risk associated with poor birth outcomes. Case management focuses on risks that are immediate (in crisis) and long-term. Case management focuses on risks that are immediate (in crisis) and long-term. Often case managers become the primary support system for women. Often case managers become the primary support system for women.

13. Why Change ? To offer women a variety of service learning that does more that focus on surface need. To offer women a variety of service learning that does more that focus on surface need. Opportunity to address the underlying social determinants that impact birth outcomes. Such as; finances, education, poverty, racism, family support and connectedness. Opportunity to address the underlying social determinants that impact birth outcomes. Such as; finances, education, poverty, racism, family support and connectedness. Provide an opportunity so that women in case management develop support among each other once case management ends. Provide an opportunity so that women in case management develop support among each other once case management ends.

14. Life Course Perspective Pilot Conducted a 6 month Integrated Life Course Perspective case management pilot Conducted a 6 month Integrated Life Course Perspective case management pilot Two levels of services offered to women enrolled in case management Two levels of services offered to women enrolled in case management Level 1 - Individual case management involved women that entered the program and were in crisis which required one on one assistance. Level 1 - Individual case management involved women that entered the program and were in crisis which required one on one assistance. Level 2 – Group level intervention planned, organized and delivered by the case managers and one community partner. Level 2 – Group level intervention planned, organized and delivered by the case managers and one community partner.

15. What was Done Case managers and the Women's Intervention Specialist were responsible for one component within the three areas of focus in the Life Course Model. Case managers and the Women's Intervention Specialist were responsible for one component within the three areas of focus in the Life Course Model.  Education  Finance  Reproductive Health  Healthy Relationships Responsibility included determining level status Responsibility included determining level status Facilitated bi-weekly group activities Facilitated bi-weekly group activities Identified additional group resources. Identified additional group resources. Managed existing caseload Managed existing caseload

16. How The Women’s Intervention Specialist completes “My Life’s Journey” (assessment) with all newly referred women The Women’s Intervention Specialist completes “My Life’s Journey” (assessment) with all newly referred women During the assessment the Women’s Intervention Specialist markets all components of the program to include the various group topics. During the assessment the Women’s Intervention Specialist markets all components of the program to include the various group topics. Assigned to case manager based on the assessment of life’s strengths and challenges with the participant to determine level of need. Assigned to case manager based on the assessment of life’s strengths and challenges with the participant to determine level of need.

17. Outcomes of Pilot The group with the most participation was the Financial Freedom Group activity “War on Poverty” The group with the most participation was the Financial Freedom Group activity “War on Poverty” Consisted of 3 six week group activities with and average of 5-8 women. Consisted of 3 six week group activities with and average of 5-8 women. Several of the women formed bonds over the six week period. Several of the women formed bonds over the six week period. Level of excitement leading up to the next group. Level of excitement leading up to the next group. Increase in financial knowledge Increase in financial knowledge

18. Lessons Learned Focused on several groups simultaneously with a new model. “Too much too fast”! Focused on several groups simultaneously with a new model. “Too much too fast”! Case mangers focused primarily on the new group activities opposed to the entire Life Course Perspective Model Case mangers focused primarily on the new group activities opposed to the entire Life Course Perspective Model Dual role for case managers proved to be a challenge Dual role for case managers proved to be a challenge Need to clarify roles continuously Need to clarify roles continuously Did not have an opportunity to evaluate the Goal Attainment Scale during the process. Did not have an opportunity to evaluate the Goal Attainment Scale during the process.

19. What’s Next Fully and completely implement the New Redesign to include lessons learned WHY ?

20. Benefit of Integrating The Life Course Perspective into Case Management The participants welcomed the change and were excited during the group activity. The participants welcomed the change and were excited during the group activity. An opportunity to address the social determinants that influence poor birth outcomes An opportunity to address the social determinants that influence poor birth outcomes Promoted inter-and independence while building reproductive capital in the community. Promoted inter-and independence while building reproductive capital in the community. The approach can contribute to improved self esteem among the women enrolled in case management. The approach can contribute to improved self esteem among the women enrolled in case management.

21. More Benefits Participants developed support systems that continued after case management services ended. Participants developed support systems that continued after case management services ended. Received a wealth of information and training through numerous group activities and individual case management. Reinforce! Received a wealth of information and training through numerous group activities and individual case management. Reinforce! Participants will have an opportunity to take an active role in tracking progress in achieving goals included in their life plans (GAS). Participants will have an opportunity to take an active role in tracking progress in achieving goals included in their life plans (GAS).

22. New Case Management Model Women complete a “My Life’s Journey” assessment and are assigned to Level 1 Individual Case Management. Women complete a “My Life’s Journey” assessment and are assigned to Level 1 Individual Case Management. Information gathered during the assessment will fall in one or more areas in the Life Course Model. Information gathered during the assessment will fall in one or more areas in the Life Course Model. The case manager and the participant will develop a Life Course Plan from the information gathered during the assessment based on areas in the Life Course Model developed by Dr. Michael Lu, MD. The case manager and the participant will develop a Life Course Plan from the information gathered during the assessment based on areas in the Life Course Model developed by Dr. Michael Lu, MD.

23. The Plan The individual Life Course Plan is participant- driven with established goals and address needs in three areas: The individual Life Course Plan is participant- driven with established goals and address needs in three areas:  Access to preventive health care and related risk reduction services that improve a woman’s chances for healthy birth in the future. This includes basic reproductive health services, such as GYN care and family planning, as well as care for chronic diseases like diabetes, hypertension and obesity

24. Life Course Plan Continued Areas  Family and Community support including activities that provide at-risk women with the skills to develop healthy relationships and connectedness with communities through civic engagement and participation.  Reduction of poverty and social inequities that assist participants in completing their education, gaining job skills, confronting discrimination and racism, and developing financial literacy.

25. Developing The Life Plan Case manager assists in the development of the participant- driven life plan through the use of 5 questions specific to each of the three areas to identify a life plan. Case manager assists in the development of the participant- driven life plan through the use of 5 questions specific to each of the three areas to identify a life plan.  Access to preventive health care/reproductive health. 1. Do you hope to have (more) children? 2. How many children do you hope to have 3. How long do you plan to wait until you (next) become pregnant. 4. What do you plan to do until you are ready to get pregnant 5. What can I do today to help you achieve your plan? Reproductive Plan Questions taken from a presentation by Merry-K Moos at the Preconception Health an Health Care Conference, October 2007.

26.  Family and Community Support 1. Who is your favorite family member? 1. Who is your favorite family member? 2. How do you gain friendship with others? 3. What activities do you like? 4. Do you want to help others? 5. How can I help you develop healthy relationships? relationships? The questions are merely examples but necessary in assisting participant in the development of a Life in assisting participant in the development of a Life Plan. Plan.

27. Group Level of Service Participants are enrolled in external group activities that are specific to their Life Plan. Participants are enrolled in external group activities that are specific to their Life Plan. The groups are scheduled through external resources relieving the case managers of the responsibility. The groups are scheduled through external resources relieving the case managers of the responsibility. Case managers’ responsibilities include notifying management of any external groups, assisting participants with access to the activity and encouraging participation Case managers’ responsibilities include notifying management of any external groups, assisting participants with access to the activity and encouraging participation Body and Soul Reproductive Health Group is conducted at the Magnolia Project where clinic services are provided. All participants are encouraged to complete the reproductive health group on site, facilitated by the Health Educator. Body and Soul Reproductive Health Group is conducted at the Magnolia Project where clinic services are provided. All participants are encouraged to complete the reproductive health group on site, facilitated by the Health Educator.

28. Monitoring Progress Participants take an active role in monitoring their progress in achieving their goals included in their “life Plans.” Participants take an active role in monitoring their progress in achieving their goals included in their “life Plans.” The Goal Attainment Scale (GAS) is used to determine progress. The Goal Attainment Scale (GAS) is used to determine progress.

29. Example of GAS Tool

30. Simplified Simplified Complete My Life’s Journey assessment Complete My Life’s Journey assessment Assigned to my case manager Assigned to my case manager My Life Journey information falls within 3 areas of the Life Plan Model My Life Journey information falls within 3 areas of the Life Plan Model Develop My Life Plan using 5 questions Develop My Life Plan using 5 questions Begin in individual case management Begin in individual case management Attend group activities (level 2) ensuring that my plan has continuity. Attend group activities (level 2) ensuring that my plan has continuity. Track My Life Plan Goals using a GAS tool. Track My Life Plan Goals using a GAS tool.

31. The Life Plan Perspective Change in approach = positive response from participants, MOST staff Change in approach = positive response from participants, MOST staff Model has impacted the way we do business Model has impacted the way we do business Use of life course framework in update of Healthy Start Service Delivery Plan Use of life course framework in update of Healthy Start Service Delivery Plan New collaborations in economic self-sufficiency, community development New collaborations in economic self-sufficiency, community development How to incorporate in state HS case management?? How to incorporate in state HS case management??

32. Questions? Thank you! Questions? Thank you!