Outreach and Outcome: Does the Boston Healthy Start Initiatives Interconception Care Model Make a Di

1
Outreach and Outcome Does the Boston Healthy
Start Initiatives Interconception Care Model
Make a Difference?

• Lois McCloskey DrPH, Penny Liu ScD MPH,
• Xandra Negron BA, Rosie Munoz-Lopez MPH,
• Snehal Shah MD, MPH, Barbara Ferrer PhD, MPH, MEd

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Background

• Boston Infant Mortality
• Boston Healthy Start Initiative

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Infant Mortality in Boston

• Black infants 3-4 times more likely than white
  infants to die in first year of life and to be
  born at low weight
• Black IMR 13.2 White IMR 3.6 (2006)
• Highest proportion of black infant deaths and
  highest rates in Project Area in 1990s
• Black IMR in Project Area 11.5 (2002-06)
• Despite slight improvements in black IMR,
  disparity WIDENS

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Boston Healthy Start Initiative (BHSI)

• Boston an original HS site from 1992
• Housed within Boston Public Health Commission
• Emphasizes elimination of racial disparity and
  serves only black women (self identified) in
  project area
• Includes African American, Haitian, Dominican
  women
• Focus on most vulnerable, e.g. homeless,
  substance users
• Funds network of 8 health centers and 5
  community-based agencies
• Each provides outreach and case management
  services to women and their infants from
  pregnancy until childs 2nd birthday.

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BHSI Model Outreach and Recruitment

• Community Consortium (450 members) meets
  monthlyword of mouth
• Partnerships with city-wide programs
• Healthy Baby/Child (womens circles)
• Father Friendly
• 1-800

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BHSI Model

• Philosophy
• Strength and risk-based care
• Sustain health in interconception period through
• Connectivity to health care of all kinds
• Surround services to reduce social isolation
  and support wellness
• All of this will contribute to improved birth
  outcomes, esp. among black women at highest risk
• Assessment
• Guided by Womens Health Questionnaire
• holistic assessment for self and provider
• Risks and strengths depression (Becks),
  smoking, alcohol and substance use, domestic
  violence, housing/homelessness, weight, family
  and social supports and relations

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BHSI Model Interconception Care

• Case management assures
• Use of prenatal and postpartum care
• Medical home connection to primary care
• Oral health
• Mental health
• Family planning
• Case manager provides
• Health education
• Advocacy
• Social supports and referrals (e.g.
  housing,domestic violence, nutrition)

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BHSI Model Case Management

• Structural Characteristics (M..Issel et al,
  forthcoming)
• Staff mix RNs, SWers, and paraprofessional case
  managers. At each site
• .5 RN
• .2 SW
• 2 case managers (average case load20)
• Source and timing of referral in during
  pregnancy but how and when varies by site
• Integration with PNC yes in clinical sites, no
  in community agencies
• Setting 2 home visits per quarter plus clinic
  and community visits

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Our Study

• Design and Data Sources
• Analytic Methods
• Findings

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Evaluation Questions

• Does BHSI improve the likelihood that clients
  receive early and adequate prenatal care and give
  birth to healthy babies?
• How do BHSI clients compare to their counterparts
  in the Project Area with respect to prenatal care
  use and birth outcomes?
• What would you expect to find?

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Study Design and Data Sources

• Retrospective cohort study
• First known study to link HSI data to vital
  records
• Data Sources
• BHSI program data 2001-2005 (intake only)
• Massachusetts vitals records 2001-2005
• Birth file
• Linked birth-death file
• Fetal death file
• Comparison group live births or fetal deaths to
  black women who lived in the BHSI project area
  and gave birth 2001-2005

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Data Linking Process(Deterministic Matching)
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Study Population

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Variables

• Exposure BHSI participation status
• Socio-demographic characteristics mothers age,
  country of origin, marital status, educational
  attainment, health insurance for prenatal care,
  plurality, parity, gravidity
• Clinical characteristics smoking status during
  pregnancy, chronic hypertension,
  pregnancy-induced hypertension, gestational
  diabetes, seizure disorder, previous preterm
  birth, small for gestational age, method of
  delivery, complications of delivery, babys sex

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Variables

• Outcomes
• Use of prenatal care
• Timing lt 4 months gestation
• Adequacy Inadequate or Intermediate
  (Kotelchuck
  Index)
• Birth outcomes
• Early (lt 32 wks)
• Low weight (lt 1500 gms)
• Intrauterine growth restriction (BW lt 10th
  percentile at GA)
• Infant or fetal death
• (Oken et al 2003)
• Also available breastfeeding at birth,
  maternal weight gain

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Analytic Methods

• Bivariate analyses
• Association between BHSI status and covariates/
  outcomes and covariates (chi-square statistics)
• Association between BHSI status and outcomes
• (crude RRs and 95 CIs)
• Multivariate analyses
• Association between BHSI status and outcomes with
  adjustment for significant covariates (adjusted
  RRs and 95 CIs)
• Poisson regression model with a robust error
  variance (McNutt et al, 2003)
• Stratified analysis to explore potential
  confounding and interactions

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Results
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Social and clinical riskBHSI v. non-BHSI

• BHSI infants were significantly more likely to
  be born to mothers who were
• Teenagers (26 vs. 16)
• Foreign born (46 vs. 39)
• Unmarried (80 vs. 66)
• lt High school educated (31 vs. 15)
• Publicly insured (84 vs. 63)
• Nulliparous (47 vs. 41)
• Smokers during pregnancy (8 vs. 6)
• BHSI infants were significantly less likely to
  be born to mothers
• With one or more clinical risk factors for this
  pregnancy
• (9 vs. 13)
• P lt 0.05

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Entry of prenatal care 4th month of gestation
Crude RR 0.99, 95 CI 0.96-1.01

N 1,236
N 8,659
20
Entry of prenatal care 4th month of gestation
(predicted values)
Adjusted RR 1.04, 95 CI 1.01-1.07

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Entry of prenatal care 4th month of gestation
Health insurance modifies effect of program on
prenatal care entry
P lt 0.05
P lt 0.05
Non-BHSI
BHSI
BHSI
Non-BHSI
Health insurance not associated with prenatal
care adequacy in this population
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Intermediate or inadequate prenatal care use
Crude RR 1.13, 95 CI 1.02-1.26

N 1,217
N 8,569

• Based on Kotelchuck Index (Kotelchuck, 1994)

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Inadequate or intermediate adequate PNC
(predicted values)
Adjusted RR 0.86, 95 CI 0.78-0.96

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Inadequate or intermediate adequate PNC Health
insurance modifies effect of program on prenatal
care adequacy
P lt 0.05
Non-BHSI
BHSI
P lt 0.05
BHSI
Non-BHSI
Health insurance not associated with prenatal
care adequacy in this population
25
Length of gestation lt 32 weeks
Adjusted RR 0.47, 95 CI 0.29-0.76 Crude RR
0.41, 95 CI 0.25-0.65

N 1,255
N 8,869
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Birth weight lt 1500 grams
Adjusted RR 0.71, 95 CI 0.47-1.07 Crude RR
0.62, 95 CI 0.42-0.94

N 1,255
N 8,852
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Intrauterine growth restriction (IUGR)
Adjusted RR 0.95, 95 CI 0.79-1.13 Crude RR
1.01, 95 CI 0.85-1.20

N 1,255
N 8,852

Having a birth weight lt10th percentile at a
given gestational age for non-Hispanic black
infants (Oken et al., 2003)
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LBW, preterm birth, IUGR, or fetal/infant death
Adjusted RR 0.91, 95 CI 0.80-1.03 Crude RR
0.93, 95 CI 0.82-1.07

N 1,255
N 8,872
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Summary of Findings

• Recruitment Mixed bag
• Low penetration in project area (10-14)
• Successful recruitment of women at highest social
  risk
• Lower clinical risk among BHSI clients
  appropriate in light of shift to less intensive
  clinical case management
• Access to prenatal care Excellent and more to do
• BHSI increased early entry into prenatal care and
  decreased less than adequate care
• Gains seen only for women with public or no
  insurance, not for privately insured

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Summary of Findings

• Birth Outcomes Impact but limited
• BHSI participation associated with decreased risk
  for very preterm birth (after risk adjustment)
  and very low weight (before risk adjustment)
• Could reflect lower clinical risk of BHSI clients
  and/or
• Impact of the program on the birth outcome most
  associated with stress related to high social and
  environmental risk
• However, timing of entry into program unknown
• BHSI participation NOT associated with decreased
  risk for restricted growth or our composite
  measure of bad outcome

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Our Findings In Context

• Limitations of Study
• Questionable validity of vital records data on
  risk factors, esp. clinical risks
• Unable to measure exposure to other interventions
  in client and non-client group (e.g. city-wide
  HBHC)
• Unable to link to BHSI program data
• dose of services
• content of services
• intermediate outcomes, e.g. medical home,
  resolution of mental health and social risk
• No information on longer term effects to reflect
  interconception care model, e.g. subsequent
  pregnancies and womens health over time

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Our Findings in Context

• Our findings consistent with prior studies on
  pregnancy-related case management
• (M. Issel et al forthcoming)
• Most show significant positive program effect on
  prenatal care use
• Some show positive effect on birth weight
• Clearest evidence for nurse case management
• (Olds D et al 1986, 1988, 1993, 1997)
• Newest evidence favors cognitive behavioral
  models of PCM to interrupt cycle of risk
• (El-Mohandes AAE et al 2008)

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Take Home Messages So Far

• Program
• You ARE making a difference..AND
• Intensify OUTREACH to recruit more women in
  project area
• Dig deep into neighborhoods, housing developments
• Restore capacity for focus on CLINICAL high risk
  to maximize ability to intervene in social stress
  and clinical pathway
• Add RN capacity or partner closely with other
  programs with clinical focus
• Apply success for PNC to PP care and medical
  home
• Special initiative to engage women with
  non-traditional risks
• Working women, women with private health
  insurance!

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Next Steps for BHSI Evaluation

• Efforts to Outcomes
• Simplified and systematic real time data system
  to track program activities and outcomes
• Will allow us to analyze social risks, referrals
  and resolutions (domestic violence, housing,
  nutrition, family planning)
• Will allow us to track womens connection to a
  medical home, prenatal care, postpartum care,
  mental and oral health care
• BHSI data and PELL data linked
• Will allow us to follow women and children
  (services and outcomes) over time and across
  pregnancies and births

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Conclusions

• BHSI is a critical part of Bostons WHOLE
  strategy to be an MCH organization that works
  upstream and downstream for women and families--
• Life course perspective
• Systems approach
• Policy change
• By digging deeper and partnering wider BHSI can
  make a bigger difference for Black women and
  infants in Boston