AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
CAROLYN SLACK: Thank you Betsy, and thank you, Nan . I am thrilled to be here today to talk to you about what happens after the feds put together laws and guidelines and give those to the states, who put together their kind of ideas of priorities and strategies that need to be done. So what happens when every, all these rules, laws, recommendations, policies, and procedures show up at our door at the local level? And I want to talk a little bit about how we’re sorting it all out, and what we see as happening, what’s working, what’s not working, and maybe where we can go to improve. It’s been very interesting to think about, well, the focus today is about where is Title V in health departments. And I’m not going to talk local health departments. There are really challenges about where is maternal and child health in local health departments. I belong to, as Nan mentioned earlier, CityMatCH, which is the National Organization of Urban Health Departments. And we’ve had a very interesting discussion about where is maternal and child health in local health departments.
When CityMatCH does recruiting, and wants to have a local health department join and gets in touch with the health officer, and perhaps with, first question is, well, “Can I talk to the MCH leader?” “Well, really, you don’t have an MCH division.” “Well, can I talk to the person who you think is the accountable person for maternal and child health?” It’s a struggle sometimes in health departments to find that person. So Title V is a funding stream, but finding maternal and child health in local health departments can be a challenge today with all the reorganizations. In general, when you’re talking maternal and child health, we are talking women, children, and family. And we’re talking about all the services that were mentioned before in terms of the pyramid. I find that at the local level also, a helpful way to think about the kind of work we do. So just to give you an example, so where is maternal and child health at the Columbus Health Department?
Well, we are probably a very odd local health department in that we now have a maternal and child health division. Well we had a change of health commissioners, we have a new health commissioner who’s background is a pediatrician. And as she reorganized the department, she felt it was very important to have a very visible, upfront place for maternal and child health. So within our department, we do have been an MCH division. It includes our MCH home visiting in a service coordination piece, in terms of things that would be familiar throughout the country. That’s where a lot of our newborn home visiting, early intervention, and Part C work takes place. WIC, WIC within our local health department is a huge program in terms of budget, and I think in terms of state agencies, it’s a huge program in terms of budget.
So, if we want to talk about accessing in connections with women, children, and families, WIC is a wonderful place to do that. We serve close to 31,000 families through our WIC program, or 31,000 participants. So again, it’s a huge program. We have some outreach programs, community outreach, care coordination, funded by all kinds of monies. We have community development, Block Grant monies, we have children’s trust fund monies, which come from local filings of divorces and birth certificates and that type of thing. And then we have some state and perhaps a little bit of Title V money in our Ohio Infant Mortality Reduction Initiative. Again, three different funding streams with three different, you know, rules and ways you do stuff, but very similar programming. We have childhood injury prevention in this division, and then we also have what we call our women’s health services, and I’ll talk about in a minute, a lot, most of our Title V funding flows into that piece of it. But that division isn’t the only place where I think of MCH, where there are women, children, and families.
We have a huge infectious disease division, which has our sexual health clinics, our communical disease and immunization pieces. Within another division, we have the breast and cervical cancer program. We have lead poisoning is in our environmental health division, and then with our planning division is our child death review. So again, when we’re talking MCH, we’re talking about in our department, making sure we’re coordinating within the division, but also coordinating within the department. And then, the special program for children with special healthcare needs, those nurses that have funding from Title V are in the Franklin County Health Department. So in Ohio , we have, cities often have their own health department and there’s a County Health Department. So again, we need to work very closely with another health department within our county, to assure that we’re thinking about, and doing the work we need to do around children and families.
The other thing I think about probably and Nan mentioned this too, if we talk about a huge public health program that’s providing direct health care services and some enabling services, is the Medicaid program. And within Ohio , Medicaid is a separate state agency from the state health department, and at the local level is also a separate county agency, rather than the health department. So again, that huge public health program, we need to be very intentional about our work to bring all that together. In terms of Title V, as a county, this Columbus Health Department is the grantee for those funds, and we receive about $900,000 a year. The city health department puts most of that money into our women’s health services, which is direct care, enabling services, and some population services. A lot of the other work we do around, through this funding is really city-funded money, because there really isn’t enough to do that.
A great amount of the money goes to our children’s hospital, and then to the OSU high-risk project. Over the last five years, the money that has come to us through this funding stream has decreased over 27%. So again, as we had decreases each year in terms of what we’ve been able to do with our Title V funding for women, children, and families in our community. Again, a little bit about what we do with our, again, all levels of the pyramid, work is done, but some of those funding. But again, a lot of the other work is done beyond that funding. I think it’s interesting when we think about the Title V imperative to protect and promote the health of all women, children and families, to really follow that through. From, from my idea, let’s focus on the work that’s being done, not necessarily on the dollars. Again, we do all levels of the work along the pyramid, and I do want to particularly talk about the challenge of talking about infrastructure services. If we want to bring in members of our city consul or the mayor’s office, or our state legislators, or our members of Congress to talk about the work that we do in MCH, while it’s the base of the pyramid, we certainly can’t bring them in and talk to them about our needs assessment and give them a cool little PowerPoint. They want to see actual people who are receiving services.
So again, there’s that inherent tension of while it’s the base of the pyramid, the folks from whom the money ultimately comes, they want to know, well how many people are you seeing, and can I come and see what you’re doing. And for them, seeing what we’re doing isn’t taking a look at our needs assessment. It’s taking a look at the people that we’re serving. So, interesting things to work through the whole political piece of that. I do believe that the infrastructure piece is just such a critically important piece of the work that we do, and trying to explain what exactly does that mean, and giving an example of what you do. So I wanted to talk a little bit about--
Unidentified Speaker: (inaudible).
CAROLYN STACK: No
.
UNIDENTIFIED SPEAKER: Escape.
CAROLYN STACK: Oh, escape. Okay, I was doing, got you. Thank you, technical assistance people. I appreciate it. When I think about infrastructure building, trying to explain what that work is, and I’m going to do it with the example of the issue of addressing prenatal care capacities, a major issue in our community. I’d like to think about it, the things that we have to get together. We have to get our knowledge base, we have to get our data together to have that makes sense. We have to talk about what’s an effective social strategy, thinking those through. Working together as a community to put those together. And then the final thing to make all of that work, is you have to identify and work with and try to get some political will to make that happen. And, I think as both Nan and Betsy have mentioned, right now, the political will to invest in women, children, and families is becoming much more of a challenge than I think it has been for a very long time. And I’ve been in public health a long time. So let me walk you through an issue, a real life issue that we’re dealing with today, and the slides are even out of date, ’cause we had our next great big meeting on Friday again, so I didn’t have time to update the slides.
For us, prenatal care capacity has been identified as a problem. I’ll get you the data in a minute. But when we were putting together our first big community forum on this, we really discovered, based on the fact that the reporter who came to cover it, we still have to make a case of why prenatal care is important, what does prenatal care mean? I think for us in this room, it could be pretty comfortable like it’s a slam-dunk. Obviously, we’re in support of prenatal care, obviously we need it. But the reporter who came to our big round table we held was, “Well, why is it important, what is it? What happens there?” He was not a parent, had no idea. And one of the things we thought about, we need to put together a business case for prenatal care. Why is that important? Part of me resents the fact that we have to go back and do that again, but again, who’s our audience? Who do we have to influence to make a difference? So again, trying to think through and explain to folks why this is really important. And it’s not just to those of us who are in this room or in the room where we were before.
So, there we are. We took time to go through and we looked at a lot of different data. Again, having that knowledge base, being able to provide the data and information that can support, and again, probably typical figures all over the place, Franklin County is the county in which the city of Columbus sits, so again, we took data talking about racial and ethnic disparities in terms of first trimester access to care. Again, when we took a look at women who have no or unknown prenatal care, again, we see the persistent racial and ethnic disparity pieces. We talked about, oh good, the Website doesn’t show on here. I’m glad it does up there. We talked about, we’ve been very fortunate to be able to be part of the CityMatCH CDC March of Dimes National Practice Collaborative on perinatal periods of risk. And later on in this conference, actually on Wednesday morning, there are a couple sessions about perinatal periods of risk, about what we learned. But if you go to the CityMatCH Website, there’s a whole methodology explanation up there.
It is a very unique and different way to look at and understand why babies die in our communities. Powerful planning tool. But again, for us, as we worked with those data, what we discovered, which shouldn’t be a surprise to anybody, is that with the risk factors were very low-birth weights, statistically significantly, we found prenatal care was a piece of that. And also that obviously, very low-birth weight, pre-term birth contributes to infant mortality. Stuff that we probably could recite in our sleep, but it’s important then to talk about, you know, what are the data, you know, so why is prenatal care important? Let’s put these things all in a row, and make it seem logical. And it is. Again, the data that really can help drive home our story, for our city and county, as for most major cities and counties and for most states, looks like the overall trend line of infant mortality is going down.
Interestingly for us, when we took a look at the disparity, the disparity between black and white moms persists. But the other thing, when we did an analysis of the trend line, you know, what’s going on with the disparity, our disparity is increasing. So while the overall infant mortality rates are going down, disparities are increasing. This was a terribly important message to get out to our community. Our Council on Healthy Mothers and Babies, this is, I talked about at the beginning, working with coalitions, the Council on Healthy Mothers and Babies has been around since the early-’90s, whose work is to reduce infant mortality. It’s kind of the bottom line of what we’re looking at in that group. We started out as a kind of a collaborative group, and then in the last two years, became a small not-for-profit with the Board of Directors. And I’ve continued to work with this group. One of the things the council has done since the early ’90s is do waiting times for first prenatal care appointments.
So we have our coordinator who calls up all of the hospital outpatient clinics, all the federal health center sites and the Columbus Health Department sites to see how many days before I can get in for a new prenatal care appointment. And we do this about three to four times a year. We publish the results, what the wait times are for all the providers. And then behind that, there’s a whole spreadsheet that just goes to the providers and gives them incredibly useful information like, how many times did it take to call through and get to talk to somebody? How long was I on hold waiting for that appointment? This has been a powerful thing for our coordinator to do. Just as an aside, the first time we had her do this survey, she was new and I told her, well, these are the places you should end up getting prenatal care appointments. But I’m not going to give you the phone numbers. Go find them and get to those places. And she has said, as a licensed social worker, it’s the most powerful thing she has ever done. She found in the Yellow Pages, kind of a generic thing.
There was no really neat place about if you want prenatal care. But there was this kind of vague thing, like pregnancy care. And within that list, there were a couple of the health department sites, maybe three of the health center sites and like four of the hospital sites. She called all those numbers. Every single one of those numbers was a fax number. And we didn’t know that before. And she just has incredible stories. The highest she went to when she called a hospital system, it took 17 transfers to get her to the place where she could make the prenatal care appointment. So we talk about moms who are new to a community, or this is their first time pregnant, the struggle they have to go through to find prenatal care. So needless to say, this survey has been a powerful tool for us, also to know the folks who are answering the phone, what are they telling people when they call up? And every time the survey comes out, you just kind of cringe and think, “Oh gosh, what did somebody say? That we need to go back and fix?” But again, we need that information to know.
Well, anyway, the range for some of these appointments has been, the lowest we had is like waiting nine days, which is great. But up to 59 days, you know, these, that’s practically a trimester before you get into prenatal care. So this is one of our indications that we’ve got issues with capacity. The other thing that’s happened particularly in the last 15 to 18 months is that every time we do the survey, several proprietors will say, well, we’re booked so far out we’re not even going to schedule appointments. So again, that’s one indication, we’ve got some capacity issues. Again, this is a little chart of over the years, how the weight times have gone. I don’t need to do a trend-lined analysis to say that line’s going up. So again, we’ve got some issues here. Again, powerful stuff for not only our providers to see, but our policymakers and funders that, you know, this is something we need to think about.
Pregnancy Care Connection, now this is a happy story about a year and a-—well, it was more than that, this line opened in August of 2003, but took about a year to plan. Based on the waiting time stories we had about, you know, not being able to figure out, you know, how to get through to a place, we’ve convened a group through the council of again, all the health centers, the hospitals, and the Health Department say, “Can we all work and develop one phone-line that women can call to schedule an appointment?” It did take a year to get that done, because everybody was really concerned. The hospitals said “Now, now, if they want to come here, you’re going to let them come here, right?” “Absolutely.” So it was a work where all the providers donated slots to give to the Pregnancy Care Connection line. And after about a year of work, in August of 2003, we implemented that line. Since that time, through Pregnancy Care Connection, over 2600 first prenatal care appointments have been scheduled. What was interesting though, again, to figure out what exactly is our capacity?
Before we opened the line, we did a survey of all the providers. And, we had at that time, again, hospitals, health centers, and health departments, we had 15, a little over 1500 slots available a month for first prenatal care appointments. Well we opened the line in August of 2003, and at first obviously, the waiting time for Pregnancy Care Connection folks, they could get in much quicker then if they called us directly. But after a while, it’s now close together. At the last survey, it was like 18 days for Pregnancy Care Connection, on average, and 22 for calling the provider directly. And we thought, boy, what’s going on? So we did another analysis of, well, let’s check our capacity again. Did that same survey and found that we have dropped over in the community a little over 1,000 slots. That’s a 31% decrease in capacity for first prenatal care appointments in the systems that would serve on underinsured and Medicaid covered women. So we took a step back and said, “Okay, what’s going on?” Well, for us at the Columbus Health Department, that 27% decrease finally took a hit in the last two fiscal years.
Finally in fiscal year ’04, we had to actually close one of our sites because of loss of funding. And this year in fiscal year ’05, we had to reduce one of our physician contractors who had provided services. So, we lost capacity that way. In addition, we’re a provider that serves a huge number of women, over 40% of our clientele are Hispanic women who are undocumented. So, maybe, like five to seven years ago, we were serving a lot of women with Medicaid, so we had some revenue that would help cover costs, but we’ve also lost that revenue piece. So that’s our contribution to decreased capacity. Our neighborhood health centers receive a huge amount of money from city funding, over $5 million in addition to federal money. But again, those monies have gotten tighter and have been reductions. So, we’ve had to, the health center system consolidated a couple of sites. So for example, when St. Marks consolidated with St. Stevens, and St. Marks had eight hours of prenatal and St. Stevens had eight hours, when they consolidated, there was then eight hours. So, we lost capacity that way.
For the hospitals, one of the biggest changes for them was when we did a talk with all those providers was the change in the residency loss. And they passed laws that residents couldn’t work more than 80 hours a week. Pretty reasonable, you know, I mean, okay. I can get that. However, where the biggest hit took place in the hospitals in all of their outpatient settings, but also in the obstetric part of it was they lost residents in those clinics, so therefore they reduced the number of clinic hours. So, that’s what’s going on in that field. In addition, again, our community has had a huge increase of two populations, undocumented Hispanic women, and we have a huge Somali population in our county. What that means is that you are now providing services where you need to include an interpreter, just think, through everything I’m saying now, we had to stop and have someone translate it. It takes much, much longer. So again, where for example, maybe you could see four patients in an hour, now two, three if you’re lucky, because it takes so much longer to do the interpretation piece.
Therefore, that reduces your capacity to see as many folks and you need to schedule fewer appointments. That’s all part of it. And then I think the huge elephant in the room, which is not a silent elephant at that, is this whole issue around obstetric malpractice and liability insurance. We’re already finding many physicians in our area are leaving their practices. And you can be assured, if women who have insurance are going to be challenged finding care, the trickle-down effect for uninsured and Medicaid covered women is going to be exponential. So again, this is a huge thing that is affecting us. I also had an opportunity to talk with our director of our residency services at the Ohio State University . And the number of folks applying to become OBGN residents is dropping quite a bit. So again, now and into the future, we could have a really big problem with this whole OB piece. So anyway, this explains, well, no wonder we’re having problems. There’s a lot of stuff going on here.
So again, all part of our infrastructure, we’re putting that data together, doing the exploration about what’s going on, what do we need to be thinking about. We, in October convened a stakeholder meeting. And again, the political will piece, we asked our city councilperson, who is chair of the health subcommittee to co-chair that with the Council on Healthy Mothers and Babies, gave us immediate credibility and assurance that the press would show up, which is something else we wanted to have there. And she has just been a real champion for what we need to be doing to be thinking about this. We put together, we, we’ve put together work, we, well, we presented some ideas, and then heard from everybody in the room, well, what are some things to think about? And we really had four things that bubbled up. One was pursuing the Family Planning Waiver. And, you might say, “Well, what does that have to do with prenatal care capacity?” But the thought was, and Nan and I are really on the same page in this. If we want to improve birth outcomes, improve the health of children, we need to improve the health of women. One way we improve the health of women is assuring that they can have health services.
In Ohio , the only time a woman can get health service is if she gets pregnant. Sixty days after the pregnancy is over, her Medicaid coverage is lost. So again, for us, the whole idea that a Family Planning Waiver would help was expanded the period of coverage, work on not only helping with inter-pregnancy intervals and what have you, but addressing all those health issues, that women stumble into our doors pregnant, carrying a incredible disease burden that we’re hoping we can fix within maybe, you know, the six months we had them in prenatal care and then 60 days afterwards they’re gone. So that’s been an important piece for us to think about. So we’ve been able to engage at our forum, both, we’ve had both state health and state Medicaid folks attend these forums, and are working on this work on the Family Planning Waiver, which I’m leading at the time.
We also have a group that’s working on the proposal to increase the cigarette tax, and actually take the money and put it into health. So yeah, really, what a unique idea. So, since I think all of our states are struggling with what’s going on with their tobacco settlement money. I know in Ohio, it’s, well, here’s a great way to balance the budget, and taking it and saying, “You know, we’ll pay you back in like 2015 or something,” hoping we’ll all be gone by then and maybe forget. But, but we won’t. We’re also, one of the other issues that really have come-up, again, we’re serving a huge population of Somali families and now Bantu families. But Columbus interestingly is a secondary migration site. A lot of folks go to Minnesota . Somebody was here from Minnesota or Minneapolis first. But again, then we have a huge group that’s secondarily settled in Columbus . However, those supports, in terms of Medicaid and what have you, all those things don’t necessarily follow. So we’re trying to make sure that is in place. And then we have a group that’s working on public awareness.
Back to that whole loop of explaining to folks, saying, why is prenatal care important? Let’s put that business case together and figure out why it’s a good investment. We did have another meeting just on Friday, again for the four workgroups to get together, and again, the political will piece is so important. We’ve got an aide from one of our state Senator’s office, who’s very interested in helping with the whole Medicaid waiver piece, and wanting to facilitate what she calls the power conversation. And even think about way we request data, a lot of times, if data are requested by a state Senator, it might be a more responsive request, rather than as we as a local collaborative said we wanted some data from Medicaid.
So again, all kinds of strategies, this is infrastructure work that will make a difference and will help us deal with providing the direct services, the enabling, and the population. And again, to bring in some of our policymakers as part of that work helps them also understand when we use that term infrastructure, well, this is the infrastructure work we’re doing. Oh, okay, they get partnership building and coalitions and things like that. But to me that whole infrastructure piece needs such translation. Again, this, the whole idea that, you know, this may not be Title V dollars, but certainly is Title V philosophy, and Title V imperatives is if you looked at the list of things that Nan talked about that Title V needs to be thinking about. And again, all of these things that we’re gathering through this infrastructure process is an important piece of our local Title V needs assessment that we’ll put together.
I want to end, oh her picture doesn’t pop up. Well, on the handout I gave you on Julia Lathrop, like Betsy, I love history, and I love what was going on from the 1890s to the early-1900s. Incredibly strong women were in fantastic leadership places, and really blazing forward that whole child welfare, child health. And again, this quote is one of my favorites. In terms of public health, if in the whole field of public health, you could only have one number to describe the health of the population, it would be the infant mortality rate. There is no more sensitive index of a community’s health. And when I read this quote about talking about that the modern view has ceased to be fatalistic, the infant mortality is regarded as a preventable waste. We have so far to go in terms of getting to that piece of it. And I want to end on the little one-pager hand—oh, here’s her picture. That’s Julia Lathrop. She was a woman who was put, appointed to be head of the Children’s Bureau, which was pretty significant in and of itself.
Finally, there’s a study which I reference on the handout, if you want to understand what maternal and child health is, and what it can be and what it should be, taking a look at that first study that the Children’s Bureau put out was the study of infant mortality in Johnstown, Pennsylvania. And, I use that for a lecture I do on maternal and child health epidemiology at Ohio State . The methodology there in both, in terms of the quantitative and qualitative, they looked at the vital statistics system. They did interviews with families. These women, who are primarily women who did the study went out, took pictures of where women lived. They talked to them about their employment, the employment of their husbands, their education, all of those things. And now we’ve rediscovered the social determinants of health. I do believe that if we had taken the recommendations that were put forth in that study that was published in 1915, we probably would not be dealing with some of the issues we are today. So again, we have a very rich history in maternal and child health, and a lot to learn from that history that will help us do the work we need to do. Thanks.