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Implementing Interconceptional Care: A State Example

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USA. Persons under 5 years old 7.1% 6.8% Source: U.S Census Bureau 2000 ... Illinois 1 of 4 states. Targeting communities on Chicago's west and south sides ... – PowerPoint PPT presentation

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Title: Implementing Interconceptional Care: A State Example


1
Implementing Interconceptional Care A State
Example
  • Ralph Schubert, M.Sc., M.A.
  • Illinois Department of Human Services
  • Anne Marie Murphy, Ph.D.
  • Illinois Medicaid Director
  • June 21, 2005

2
Illinois . is the state most demographically
representative
of the nation as a whole
Source U.S Census Bureau 2000
Illinois
USA
USA
Illinois
  • Persons below poverty ( 1999) 10.7
    12.4
  • Persons under 5 years old 7.1 6.8
  • Persons under 18 years old 26.1 25.7
  • Female persons 51.0 50.9
  • H.S. graduates more than 25 years
    old 81.4 80.4
  • White - not of Hispanic origin 73.5 75.1
  • African American not Hispanic origin 15.1
    12.3
  • Hispanic 12.3 12.5
  • Asian 3.4 3.6
  • Native American 0.2 0.9

3
Maternal and Child Health in Illinois
  • 180,000 live births per year
  • 45 of live births covered by Medicaid
  • Disproportionate number of high risk births
    covered by Medicaid
  • 66 of Medicaid births are unplanned
  • 30 of Medicaid births are to undocumented women
  • If you want to improve birth outcomes,
  • Medicaid is the place to start !!

4
Other Maternal and Child Health Programs
Intertwined with Medicaid in Illinois
  • Title V Maternal and Child Health Block Grant
  • Title X Family Planning
  • Family Case Management Program
  • Targeted Intensive Prenatal Program
  • WIC
  • Perinatal HIV Testing and Counseling
  • Smoking Prevention
  • Mental Health Treatment
  • Alcohol and Substance Abuse Prevention and
    Treatment

5
A Majority of Medicaid Births are Unintended or
Unplanned
6
A Majority of Medicaid Births are not a Womans
First Birth
In CY01, 65 of Medicaid births were subsequent
births
7
Medicaid Covers a High Proportion of
African-American Births
8
Hispanics and Latinas Births Are Also More Often
Covered by Medicaid
9
Prenatal Care
Approximately 71 of Medicaid women enter
prenatal care in the first trimester. (CY 2001)
10
Very Low Birth Weight Rate Medicaid 1.7 (CY 01
Birth File Match)
11
Low Birth Weight RateMedicaid 9.5(CY 01 Birth
File Match)
12
CY 2001 Percent of VLBW By Chicago Community
Area  
13
CY 2001 Percent of LBW By Chicago Community
Area  
14
Incidence of Non-Normal Medicaid Births By
County (1999-2001)  
15
Adequacy of Prenatal Care
  • Approximately 75 of Illinois pregnant women are
    receiving as much prenatal care services as they
    should (Kessner 74.5 Kotelchuck 77.5)
  • Approximately 62 of Illinois Medicaid pregnant
    women receive adequate prenatal care (Kessner)
  • Those enrolled in WIC or FCM achieve better
    compliance (65 vs. 53 Medicaid population
    without WIC/FCM)

16
Medicaid Delivery Claims
  • Approximately 16 of Illinois Medicaid
  • women who delivered with complications did
  • not receive any Medicaid-funded prenatal
  • care.
  • Approximately 14 of Illinois Medicaid
  • women who delivered without complications
  • did not receive any Medicaid-funded prenatal
  • care.

17
Where does that leave us?
  • Many women are receiving prenatal care but still
    not having good birth outcomes.
  • Some women are not getting into prenatal care.
  • This implies that we need
  • New approaches to outreach
  • New models of care including pre or
    interconceptional care.
  • Analysis of the quality of prenatal care needed

18
Needs Assessment
  • Perinatal Periods of Risk
  • Interpartum interval and VLBW
  • Change in birthweight distribution
  • Prevalence of medical risk factors
  • Fetal and Infant Mortality Review
  • Perinatal Task Force

19
Map Feto-infant Mortality
Post neonatal
Neonatal
Fetal
Maternal Health/ Prematurity
500-1499 g
Maternal Care
Newborn Care
Infant Health
1500 g
20
Focus on Overall Feto-Infant
MortalityBlacks, IL, 2000
Maternal Health/ Prematurity 7.8
Total feto-infant mortality rate 18.4
(633/34,314)x 1000
Maternal Care 4.2
Newborn Care 2.0
Infant Health 4.5
21
Excess Feto-infant MortalityBlacks, 2000
IL Blacks
Reference
Excess
7.8
2.9
4.9
-

4.2
2.0
4.5
1.9
1.3
1.1
2.3
0.7
3.4
-

18.4
7.2
11.2
22
Very Low Birth Weight Rates
  • The very low birth weight rate goes up as
    interpartum interval goes down
  • All women with a prior birth 1.2
  • 12-17 Months - 1.3 percent
  • 18-23 Months - 0.9 percent
  • ?24 Months - 1.0 percent
  • Illinois, 2001 - 2003

23
Interpartum Interval Among Very Low Birth Weight
Infants
  • Among VLBW infants born to women with a prior
    birth
  • 14 born within 12 months of the prior birth
  • 16 born between 12 and 17 months
  • 11 born between 18 and 23 months
  • 59 born more than 23 months

24
Change in the Birthweight Distribution
25
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26
(No Transcript)
27
Are women healthy?
The most common health problems of
African-American women in Chicago who had a very
low birth weight infant were
  • infections
  • drug abuse
  • asthma
  • hypertension
  • anemia
  • premature labor
  • prior pre-term birth

28
FIMR Findings
  • 62 Lifestyle Issues stress, unplanned
    pregnancy, alcohol/drugs/smoking, no PNC,
    domestic violence, jail
  • 22 Medical Issues prior pre-term birth or fetal
    loss
  • 12 Systems Issues poor communication, lack of
    referrals, lack of resources
  • 4 Environmental Issues poor social support

29
FIMR Categories
4 4 Environmental
22 Medical
12 12 System
662 Lifestyle
30
FIMR Lifestyle Factors
31
FIMR Medical Issues
Management of pre-existing medical conditions and
issues related to current pregnancy or
post-partum period
  • Maternal pre-existing conditions
  • Medical conditions related to current pregnancy
  • Multiple birth pregnancy
  • Lack of pregnancy evaluation during sick
    physician visits
  • Congenital anomaly
  • Depression
  • Family Planning issues
  • Lack of risk assessment
  • Infections
  • Incompetent cervix
  • Previous pre-term labor
  • Pre-term labor

32
Perinatal Report
  • Public Act 93-0536
  • Passed with the aim of improving birth outcomes
  • Perinatal Task Force other state agencies
    experts in perinatal care
  • Priority Recommendations to the General Assembly
    www.illinoishealthywomen.com/report
  • Report required every 2-years

33
Perinatal Report (continued)
  • Priority Recommendations and Initiatives
  • Expansion of FamilyCare
  • Expansion of Family Planning Waiver
  • Addition of Targeted Intensive Prenatal Case
    Management for High Risk Pregnancy Sites
  • Development of a Smoking Cessation Program
  • Pilot for outreach to locate hard to reach
  • Creation of a Statewide Mental Health
    Consultation Service
  • Development of interconceptional care
  • Medicaid reimbursement for Preconception Care

34
Current Strategies for Providing
Interconceptional Care
  • Folic Acid Campaign
  • Title X Family Planning
  • Illinois Healthy Women
  • FamilyCare
  • Family Case Management and Healthy Start
  • WIC
  • Closing the Gap

35
Folic Acid Campaign
  • Collaboration between WIC and Illinois March of
    Dimes
  • Distribute prenatal vitamins through WIC and some
    Title X agencies
  • Screen postpartum women in WIC on folic acid
    intake counsel
  • Birth Defects Awareness Month activities
  • WIC Food Package provides folic acid
  • IDPA coverage of folic acid and multivitamins
    with folic acid

36
Title X Family Planning Program
  • Key component of interconceptional care
  • Preconceptional education
  • Model protocols have standardized content but
    different target groups
  • Negative pregnancy tests
  • New clients

37
Title X Family Planning Program History
  • 1993 Training for QA staff
  • 1994 Grants to agencies for protocols, resources
    and training curriculum
  • 1994 Agencies with approved protocols receive
    reimbursement for preconceptional education
  • 2001 protocols updated

38
Title X Family Planning Program Protocol
  • Nutrition
  • Lifestyle (behavioral risk factors)
  • Family History
  • Medical History
  • Reproductive History
  • Medication Use

39
Title X Family Planning Program Status
  • 1/3 of local agencies have approved protocols
  • These agencies receive additional 5.50
  • All agencies required to provide minimal
    preconceptional counseling
  • 2004 21,160 preconception education and
    counseling sessions (up from 17,101 in 2003)

40
Illinois Healthy Women
  • 5 year Medicaid Waiver for Family Planning
  • Began 4/04
  • Women ages 19 through 44
  • No longer eligible for medical assistance
  • Limited coverage family planning and related
    reproductive health (STI testing treatment,
    mammograms and folic acid)

41
Illinois Healthy Women (continued)
  • Our View Improves Birth Outcomes
  • CMS View Birth Control
  • Amendment 1
  • multivitamins/folic acid (currently state only
    funds)
  • Amendment 2 250 of poverty
  • application process internet, point of
    service, community agencies
  • Need for coverage of preconception visit,
    smoking cessation products, maternal depression
    screening

42
Illinois Healthy Women (continued)
  • Current Status (5/05)
  • 113,998 women sent a 3-month card
  • 11,399 had undeliverable addresses
  • 25,752 enrolled for the full year of
  • coverage
  • 1,342 reenrolled for the second year
  • 15,200 program participants (utilized
    services)

43
FamilyCare
  • Comprehensive health care coverage to parents or
    relatives living with their children 18 years or
    younger
  • Income up to 185 of poverty (FY 06)
  • U.S. Citizen or Meets Immigration Requirements
  • Very modest co-pays no co-pay for family
    planning

44
Family Case Management
  • 277,300 Pregnant Women and Infants Served
    Annually with budget of 44 million
  • Intertwined with Medicaid and WIC
  • Operates statewide through local health
    departments, federally qualified health centers
    and community based organizations.
  • Outreach and Case Finding
  • Assessment and Care Plan Development
  • Referral and Follow-up
  • Advocacy

45
Chicago Healthy Start Initiative
  • Targets 6 communities around the Loop
  • Supports 4 Healthy Start Family Centers
  • Eligibility based on medical or social risk
  • Outreach, Case Management, Health Education,
    Depression Screening
  • Interconceptional Care began in 2002

46
Chicago Healthy Start Initiative
  • Service Coordination
  • Service plan focused on mothers goals
  • Measure referral for family planning and use of
    well child care immunizations
  • Health Education
  • Womens health after pregnancy
  • Substance abuse prevention
  • Domestic violence
  • HIV / STD prevention

47
Closing the Gap Racial Health Disparities at
Birth Project Funded by HRSA
  • Illinois 1 of 4 states
  • Targeting communities on Chicagos west and south
    sides
  • Working with 2 existing federally-funded Healthy
    Start Projects
  • Focus on system building rather than direct
    services

48
Closing the Gap
  • Strategies
  • Public information campaign
  • Peer counselors to change community norms on
    prenatal care and infant sleeping arrangements
  • Coordinating other federal, state and city-funded
    infant mortality projects
  • Blending state and federal funds to finance
    prenatal and interconceptional case management

49
Quality of Medical Care
  • Closing the Gap areas
  • Racial Disparities in birth outcomes
  • Michael Reese Health Trust Grant (local funding)
  • Medicaid federal match
  • Partnership between DHS, DPA, DPAs Peer Review
    Organization and UIC Endorsement from ACOG
  • Provider Survey
  • Medical Record Abstraction Tool Development
  • Development of Quality Indicators/Score
  • Study Design
  • Medical Record Abstraction Findings
  • Quality Improvement/Provider Education

50
Special Supplemental Nutrition Program for Women,
Infants and Children (WIC)
  • 508,250 Women, Infants and Children Served
    Annually with budget of 34 million food
  • Quality nutrition education and services
  • Breastfeeding education and support
  • Supplemental nutritious foods
  • Access to health care services
  • Women eligible for 6 months post-partum up to
    one year if breastfeeding

51
Additional Interconceptional Services
  • Smoking Cessation
  • Depression Screening

52
Smoking Cessation
  • Protocol (The 5 As)
  • Curriculum (Make Yours A Fresh Start Family, et
    al.)
  • WIC Visit
  • Monitor through Cornerstone
  • Medicaid provider notice
  • Medicaid reimbursement of pharmaceuticals
  • Tobacco QuitLine

53
Depression Screening
  • Gubernatorial Task Force
  • Healthy Start
  • Satellite Training
  • Medication Guidelines
  • Consultation Line Provider Training
  • Brochure
  • Medicaid reimbursement

54
Barriers To Program Expansion
  • Competing demands for money
  • Focus on infant
  • Loss of Medicaid eligibility
  • Immigration status
  • USDA WIC eligibility policy
  • CMS Policy
  • - Need waivers or other funding to test
    strategies

55
Ideas on the Drawing Board
  • DPA Proposal for Interconceptional Care Pilot
  • Public-Private Partnerships
  • Reconfigure Nursing Follow-up
  • Illinois Healthy Women Expansion
  • Role of Federally-Qualified Health Centers
  • Privately-funded WIC Expansion
  • Simplify Title X protocol
  • Interconceptional care for the undocumented

56
Public-Private Partnerships
  • Foundations providing matchable funds
  • Target high risk women
  • fetal or infant loss
  • prior VLBW infant
  • Outreach, incentives, interconceptional care
    coordination, behavioral risk reduction

57
IDPA Pilot Proposal for Interconceptional Care
  • Population women with recent fetal or neonatal
    death
  • Area City of Chicago
  • Program Components outreach, education,
    interventions, evaluation
  • Interventions provided for 2 years
  • Case Management
  • Family Planning
  • Preconception Care
  • Medical Care/Management high-risk conditions
  • Support services grief counseling, lifestyle,
    high-risk behaviors

58
Refocus Nursing Follow-up
  • Part of birth defects surveillance system
  • PHN visits for 2 years
  • Developmental assessment, anticipatory guidance,
    link to community services
  • Prioritize visits to high-risk women

59
Role of FQHCs
  • Growth in Presidents budget for HRSA
  • Explicit links to other parts of the public MCH
    system
  • Provide medical care for uninsured and
    publicly-insured women
  • Physical and mental health services for women and
    their children

60
Illinois Healthy Women Expansion
  • Expand eligibility for Illinois Health Women to
    250 percent of the Federal Poverty Level

61
Extending WIC Postpartum
  • Nutrition education and risk reduction (smoking
    cessation, folic acid supplementation)
  • Private funds to pay for maternal nutrition
    education after 6 months postpartum
  • Children continue in WIC

62
Revised Title X Protocol
  • Simplify Preconceptional counseling protocol
  • Standardize target group
  • Basic protocol for all grantees
  • Conduct training
  • Monitor implementation
  • Encourage providers

63
Summary
  • Additional Emphasis on Interconceptional period
    is justified
  • Components of interconceptional care can be
    provided through existing programs with existing
    funds
  • Foundation funding and Medicaid / SCHIP waivers
    as strategies for expansion funding
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