AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
STEPHANIE BEAUDETTE: Okay, let’s go ahead and get started. I’m going to start whipping through some slides so that we can end on time and have some opportunities for questions, even though I’m sure you would all love to spend the rest of your morning with us. I’m going to quickly kind of talk about, we talked earlier that I wanted to give you all an overview on how to do this on a "Macro" level, from state, kind of, top down, and also give you information of, what does this look like immediately within your clinic, if you’re just going to impact some change in one specific setting. So I want to talk a little bit about funding, how we rolled this out and did a pilot roll out with grantees, training, conference calls, support, the whole kit and caboodle. As I mentioned earlier, or rather Jodi did, we were lucky enough to receive a one-time grant from the Maternal Child Health Block Grant, our MCH director. They have money aside for special projects and to our credit and benefit we had a plan in place, a written plan of what we would do if we had money.
This worked to our advantage when they came to us and Jodi and said, we’ve got 100 thousand dollars, can you spend this and how will you spend it and what were you going to be doing that I can say yes this is worthy and justifiable to do. And we also have some of our MCH block grant money that we dedicate on going to this project. And again it’s piece-mealing here and there, my supervisor will say, every now and then we’ve got salary savings from this particular person or position being vacant, which makes it harder on the rest of us cause you’ve got to pick up the slack, but there’s also the piece of me that says, yeah, there goes a couple more media spots that I’m going to have out of this as a result.
So what we did is we took this 100 thousand dollar one time grant and we decided we were going to roll this out, do a train the trainer kind of model of roll out throughout the state and hit some of our biggest local health departments. And so we contacted them and tried to assess their interests, you know, would you be willing to participate with us in this venture, and what kind of money would it take to support some staff time to do this. And we had a scope of work that we had drafted that we wanted these health departments to follow. Basically, we wanted them to identify a set person or persons in their agency who would be the local coordinator that would be working with myself and Jodi on a regular basis and going out outside of the health department, which is a novel idea for some people, and working with providers in their community especially the private practioners, who seem to be the least knowledgeable of other resources out in the their community, where as the public providers have within their clinics the social workers or dieticians and other resources readily available.
We ask that the coordinator either be a registered dietician or a public health nurse who had training and experience in obviously maternal health and preferably in nutrition as well. As a dietician I was a little biased coming into this, wanting more dieticians to be our coordinators and what we really learned as a result of this is regardless of the position, the key characteristics of this person was good public health speaking qualities. We wanted someone that we could coin a drug rep personality, this is what we wanted, because there were some dieticians and some public health nurses who were much more successful in getting in the door to private practices than others. And some people, this was their biggest barrier was just getting their own comfort level up to speed to get out and sell the campaign which we already know is a hard sell to begin with for most people. So we were successful in getting six local health departments, one was contracted through a health maintenance organization and we also had Kaiser Permanente come on board to roll this out.
So we did a one-day training, this was unfortunately during my maternity leave, a one-day training for all of these local coordinators, and trained them on the campaign, how to use the tools, how to use the materials, how to get out the door. And our goal for them was to get out and train and educate at least 100 health care providers in their community on this campaign and this issue. We learned that we broadened the term health care provider a lot. From physicians to nurse practioners to dieticians to health educators to social workers, other mental health professionals, “friends” of pregnant women, anybody who comes in contact with the pregnant woman and could give a supportive message. We had folks going to just pregnancy crisis centers where all they offer is pregnancy testing, to just giving them the information that at least then if you can plant the seed with these woman and take the information, that they can take it back to their providers, going forward, that is at least one avenue that we would explore as well. And through the trainings, our ultimate goal is, it’s one thing to educate people but our big concern and our goal was that we wanted to see change in practice. And again these numbers were really just kind of pulled out of a hat, we didn’t have a magic number of 100 scientifically based, it was just a shot.
And so, some of our smaller counties had difficulty in reaching this number, again we wanted ten practices to change something, more often than not, even if this is getting a height on a woman. When Jodi and I worked at Denver Health, my graduate research was on inadequate weight gain during pregnancy and I did a chart out of it over a 150 charts and just kind of looking through and seeing what are these women gaining, whose gaining inadequately, what’s all going on. Eighty-five percent of the medical records, aside from just their OB notes going back through everything that they had, did not have a recorded height. And if you don’t have a height, you can’t assess body mass index to make appropriate recommendations for weight gain in pregnancy. So that was a huge barrier. So even something as small of a change in practices, either asking for a height or getting a stadiometer to measure a height and put it in the woman’s chart, was something that we thought would be a small success.
We also wanted them to have 500 brochures and education going out to pregnant women in their county. Again this was the hardest area to measure, this was one of our outputs that Jodi was talking about measuring of, seeing how many pregnant women are getting this information and getting education, almost all of our assistants, aside from just having a tic sheet next to the OB educators desk, of how many brochures she handed out and hopefully opening the brochure, or just saying here’s your BMI, this is what you should gain as a bare minimum for education. The Kaiser Permanente system has an electronic medical record that they would actually have a bar code sticker and they could track for us how many patients actually received education and how many referrals to the dietician were coming in as a result of their trainings that they did throughout their system.
Talked a little bit about what we did to the coordinators with trainings, we certainly could have improved upon this training and these are some of the lessons learned that I think Jodi is going to talk a little bit more about at the end. We gave them all the tools that you have here, we gave them as much literature as we could, there’s Medline abstracts and summaries so that folks could be as well versed as they could be on the subject matter, this was also a barrier from some of our coordinators, who felt they needed to have the answers to everything before they even went to talk to the providers. I think in hindsight they realized the time wasn’t there within the providers offices to get into that much detail and they could’ve gone and just started pitching the campaign and instructing them on how to use the tools and been a resource for them going forward; they didn’t need to have all of the information at once as far as what’s out in the literature today.
So we asked them to contact all prenatal care providers in their county and create a list of who they contacted. Some people were much more resourceful then others. Some people just went to the yellow pages and looked for providers. Some people went to their EPSET and said okay give me a list of all your Medicaid providers. Go to your WIC providers and whose your referring WIC providers and getting out in the community that way. There’s a lot of resources already established out there for you, that you don’t need to just go to the yellow pages and try and find providers in your community. We asked them to do an initial practice questionnaire with each agency, and this was really trying to get an idea of what was going on within the practice related to weight gain assessment and counseling and measurement.
And then after the training, three months later, what has changed if anything. So those very simple questions such as do you record a height, do you record a weight, if so, how often, what is your weight gain recommendations that you’re currently giving out, whose giving them, what do you do when you assess a problem with the weight gain, do you have referral sources in place to a dietician or a mental health professional or WIC, so on and so forth. So we did get some information here with that. We wanted them to provide a training. And this looked very different for many of the coordinators just depending on where they were geographically in the state and what resources were available. Some of the folks who worked in metro Denver , really taped into the residency programs and the nursing schools and they had full forty-five, sixty minute time slots with fifty, sixty, seventy residents at a time, it was a very didactic experience.
Others where they went out into the private practice community, it might be fifteen minutes of the staff meeting to get into the door, pitch it, sell it, here’s what it is, I’m going to follow up if you’ve got questions. Some it was, you know, very difficult to get into these providers offices and so it was something simple like leaving materials and trying to make the connection again later once they’ve had time to look through them and answer any questions they might have. We wanted the coordinators to participate in monthly conference calls with myself and Jodi. This is in essence what we wanted to create was a learning community and I feel that we did affect this but we still had kind of a leader and follower relationship, where we were giving a lot of the information, but there was a tremendous amount of learning that went on from the coordinators so I felt the other coordinators who were struggling a little bit more, really benefited from hearing some trouble shooting ideas from some of the coordinators that were very successful in getting in the door, rather than hearing it from me.
Jodi and I worked in the community health centers and that, so we have a pretty good idea of what it looks like day to day and the practices but again we haven’t been in that environment in a while so it’s good to have the folks who are out there in the trenches, giving us feedback of, this is who is the best person to contact within the agency. This connection or working in collaboration with other programs who have already been successful, for example, the tobacco cessation programs, partnering with those folks and using their connections and dove tailing on them, if providers are chomping at the bit to get someone to come in and talk to them about smoking cessation for pregnant women, can you get the coordinator for the weight gain campaign to come with them and dove tail, kind of sell it, because maybe by itself the nutrition component in our campaign might not be of interest enough to them until they learn more about it. Getting in the door was obviously the biggest challenge, everyone’s very busy and depending on who you talked to in the clinic it may or may not be an issue that they wanted to take on.
Persuading providers that this is an issue, again, the excessive weight gain was the most prevalent concern and barrier that we experienced in the coordinators experience in getting this out to the providers. Addressing and debunking myths related to prenatal weight gain. So again some of our concerns the providers will say my patients are gaining an adequate amount of weight and so talking to them about, you know here’s the stats for your county, we can pull it up and see, this is a very affluent county yet you’ve got thirty percent of your women not gaining adequately. And then here’s a rural county with the same kind of problem, here’s a metro county with the same kind of problem. So, different types of women, yet experiencing the same problems, different contributing factors, but it’s still a problem in your clinic whether you believe it or not.
Obesity is more a problem in my patients, and again talking to them, that we recognize obesity is a problem but it’s a very complicated problem and excessive weight gain is not germane to the low birth weight problem in Colorado . So that’s not where our focus is. This is a very specific campaign related to inadequate weight gain as we know, it impacts the birth weight of the infant, and so that’s why were focusing our energy on this. And other efforts should come to address the excessive weight gain. I think it was great to hear Kelly and Allison talk about that you need to stick with your message and not change course. We’ve had a lot of pressure throughout this campaign, even before getting to where we’re at now, to take a broad approach and talk about appropriate weight gain, staying within the IOM guidelines instead of focusing on the inadequate weight gain, and you know, our graphic artists, our advertising agency really discouraged that, he said you know appropriate weight gain is not shocking or compelling, inadequate weight gain is and you might irritate some people with it but at least you’ve got their attention.
So that’s what you want to get, is create that interest and let people know that this is a problem and we’re not going to overlook it and if we start talking more about the excessive weight gain all the time, this is just going to get buried. So this is some day-to-day practices that you can incorporate, basically you need an accurate scale, stadiometer, wall tape, including a prenatal weight gain grid as a standard form in all prenatal records. And this could be something where we talked about during trainings, according (inaudlibe) all levels of the staff, not just the providers, because if you don’t have a front office staff on board or you’re forms people, to get them to get this into the medical record, we’ve had folks call and say well we have an electronic medical record, we need to scan this, can you take the logo off because it takes too much memory, can you move the margins over an inch, so we can put a bar code on them and we’re willing to work with folks to do that, to make this as useable as possible.
And I’m going to go over specifically how to use this form. Including a patient education brochure, an all-new patient packet, I think most people get the whole folder or baggie of the drug rap materials Meade Johnson, Roth, Formularies and all at. You can toss this in along with all the woman's other information. Don’t just use the brochures for women who you’ve already identified as gaining inadequately, use them with everybody because you never know when that person is going to start falling off of the chart and maybe you can prevent that by giving just a little bit of information at the onset of their pregnancy. Having the BMI gestational wheel or the BMI wall chart by the scale. This is something that you can post by the scale, if you have a clinician who maybe isn’t very comfortable discussing weight gain, especially we see kind of the aversions to talking about weight gain in the overweight or obese population, if you have this there or in the waiting room while the women is sitting there in her little gown for who knows how long, maybe she can look at this, find her information, and take the initiative to ask the provider herself, well what does this mean for me and why.
At the end I was going to talk a little bit about some of the other states who’ve picked up different parts of our materials but I’ll throw this in now. I’ve heard that Vermont has taken our wheel and has blown this out to like a wall size interactive poster by the scale, so the women, kind of like Wheel of Fortune, can spin it around and see where she falls, I said, God I hope there’s a little more privacy then what she gets just standing on the scale in front of the whole office staff and every patient walks by, you know, if you flip into the orange or the yellow area, that that’s not a little disconcerting for the woman. Measure, ask for the women’s height and ask about pre-pregnancy weight. Depending on when the woman’s coming in for care, you can either make a big issue out of this or not. In Colorado we have a lot of late entry to care, not a lot of first trimester care. Go with what you got, BMI it doesn’t have to be the exact number, as long as you know the women’s category, that’s a pretty wide range and go from there, I’m going to talk a little bit more about that with plotting on the grid.
Again, here’s our grid, we went with this weight gain grid, there’s a couple of different one’s out there. This is a grid that the Colorado WIC program uses, so it’s familiar to some providers already and we thought that that would be the best received. The lines on this grid here indicate the minimum amount of weight gain the woman should gain by her BMI category. The downside of this is, it doesn’t have the excess lines to gain on there. So if the woman’s above this line, the provider without doing a little bit of math, or maybe just drawing another line down on the grid, can’t easily see if she’s starting to gain excessively. We wanted to keep this as simple as possible. There’s also some grids out there that are specific by BMI category, and so there might be two grids on one side and two grids on the back, like an under weight, a normal weight, over weight and obese. So you have four different grids. We didn’t want providers to have to determine what the BMI category was before they even put the appropriate chart in the medical record.
We just wanted one chart that covers your basis for all women in all BMI categories. Try to keep it as simple as possible. In our argument for using the weight gain grid over the ACOG or the KOPICK sheets, is this grid gives you a nice, quick, easy visual representation of where the woman is gaining. This can also be used as a patient education tool to show the woman specifically, here is where you’re at and here is where you should be. You obviously have to use caution with someone who you think is a little too body-image obsessed. And that they might follow this to the letter and get a little freaked out by going above or below the grid line that they are supposed to be following. But for many women in my experience, this has been very helpful for them and reassuring to know that the weight gain they’re experiencing is normal and expected and appropriate.
So as an example, if you’ve got a women who’s five foot two and hundred and thirty four pounds, her first visit is at twenty six weeks gestation, she’s coming in almost every four weeks, she starts off hundred and thirty seven pounds, so she has a three pound gain, next visit no gain, third visit she’s got a nine pound gain, so just with this information, as a clinician, how many pounds above or below the recommended weight is she and is she at above or below where she should be? I mean, in your opinion, would this give you enough information to identify where the women is? I’ve had providers tell me, well I know that by twenty weeks they should’ve gained twelve pounds. Well that might be fine for one BMI group woman but that’s not fine for everybody. And why keep track of every number in your head of where they’re supposed to be when, when you look at the grid you can clearly see this woman is below where she should be.
This is a normal weight woman who should be following on the green line, so even though she had that nine pound gain, which you think okay, some people might even be concerned, she gained nine pounds in five weeks, what’s going on? You obviously want to rule out preeclampsia or pregnancy induced hypertension, but she’s still very far below where she should be gaining. In the interest of time, this next one, this woman looks like she’s gaining appropriately, she’s hitting two to three pound gains almost, at every visit, at every four weeks. She’s five-six, one hundred thirty pounds, so as I know with the wheel she’s a normal weight woman. And yet when you plot her on the grid she’s falling just below the lines. Providers or our coordinators have used these power point slides here to make the case for the grid. And again, for the argument for the providers who are saying my women are gaining too much weight, is how do you know?
How do you know if they’re gaining too much weight if you’re not plotting them on a grid so that you can assess by their body mass index type, how much is adequate or excessive? Pull ten of your charts, take their information from the ACOG sheet and plot them on the grid and see where you’re at? So you’ve got a good idea of what is really going on in your clinic. On the grid, these grids here, this was our first printing run, we’ve made adaptions to the grid to make it a little more user friendly so people understand how to plot on this. There’s also detailed instructions on our website, that you can download of how to plot on the grid. Basically your vertical axis here on left hand side and on the right, are the pounds gained. Each block represents one pound gained. And your horizontal axis are your week’s gestation. So you simply start at the zero line, enter her pre pregnancy weight or her first trimester recorded weight if she has no idea of her pre pregnancy weight and calculate her BMI obviously using the wheel or the wall chart to find out what category she falls into for her BMI group.
And then just start counting pounds up and across. So if by twenty weeks she’s gained ten pounds you just go over and up and make a dot. We’ve added lines to the bottom so providers can have current visit weight, weight from last visit and pounds changed so that they can identify excessive weight gain at the bottom or our bare minimum for inadequate weight gain. Does this make sense? Does anyone have questions about how to use the weight gain grid? And then the wheel, I think, I’ll just go over that quickly, I think that’s pretty self-explanatory as well. You just dial in, find their height on the inner wheel, I believe, and their weight is on the outer and line them up and the arrow drops you down into the BMI categories below. Again we don’t have every number printed on the bottom as far as their BMI number because unlike obesity management, we’re not looking at change in BMI number, we’re looking at what category they’re in to make the appropriate recommendations.
JODI DRISKO : And the BMI categories for pregnancy weight gain are different then just the basic under weight for the NAH.
STEPHANIE BEAUDETTE: For the NAH, that’s right, thanks for mentioning that. The standard BMI categories that most people are familiar with from the National Institute of Health are for obesity management and for chronic disease management, their categories start at a different level than ours for the institute of medicine. For example, underweight for the NIH definition is a BMI less than eighteen point five. The IOM recommendations are underweight as a BMI less than nineteen point eight, so they have a higher threshold of considering someone underweight because they see more optimal birth outcomes with those women. So they want more women to fall into that category of underweight to gain more to have a healthier birth outcome than, say what the NIH does, which the women would have to be much, much thinner before she would be considered underweight. Questions about that at all? Okay, I’m going to flip back to Jodi.
JODI DRISKO : So through our pilot groups, Stephanie had mentioned that we did these monthly conference calls and we had ongoing discussions and emails with all of them and we just learned a ton about what worked, what didn’t work and how can we do it better next time. I also come from a quality improvement background, so I’m always interested in, what changes can we make to make this even better. So one of our first things we learned was to network, network, network. That a lot of these people they were in different positions. We had quite a few people who were WIC educators, dieticians in the WIC program, who often never left their health department office except to come to work and go home. So for some of them it was harder for them to network and get out of their office in the beginning, then for others.
Other people hit the ground running from day one, were out there and making it happen. So to use existing context or connections as Stephanie said with their smoking cessation programs, tobacco campaigns I think most states and local counties have some sort kind of tobacco programs going if you were part of the big tobacco settlement dollars. And also one of our coordinators worked with WIC referring physicians, for some of them, you know they get these WIC referrals, but they don’t even know who these providers are, but it’s a natural fit to introduce yourself, I’m working with your clients, because you know if you’re telling them to gain this much but the provider tells them to gain something else, who are they going to listen to? They’re always going to listen to the doctor because they know everything. So also working with these outside groups and agencies actually helped some of the health departments sell their services as the public health department, which was kind of an unexpected outcome especially for one of the counties.
They were really slow getting off the mark and they had really kind of gotten into it at almost the end of the grant period. But, they said that it was such a great experience for them because they had gotten out of their office and they could use that opportunity to tell people, we also offer these services and you can refer to us these income eligible women for nutrition counseling and other stuff. So they had also got resources from these people as they were providing them, so that was an unexpected outcome for them, I think. And I think our overall main lesson was that, to work with providers you have to get out of you office, you can’t expect that phone calls and faxes will work. And this was a problem that we probably started in our training.
Stephanie was on maternity leave, we had a consultant come in to kind of take over her duties and she had developed the training and just gave me the evaluation forms to look at and stuff like that. So I wasn’t an intregal part of the training and she hadn’t necessarily worked with providers so much, so they were told initially to make a contact phone call, send out faxes, which I think sending faxes to a providers office is just the opportunity for them to throw them in the trash and waste a lot of paper. And also to be persisant with the calling, that calling once of twice and expecting anyone to call you back is never going to happen. That they really needed to be persistent and call, not to the annoying point, but it was often trying to reach the right person in the office. Usually the practice manager, or office manager or someone like that could help them out but to the more successful people, in the beginning at least, had that pharmaceutical sales rep mentality of going out there, they would even say, I wish we could bring food because then we could just in the door so much easier.
And then we learned quickly to really think broadly about what a provider is, it’s not just OBGYN’s and nurse midwives, but it is a family practitioner, some DO’s do prenatal care, family planning clinics, some of them went to the pregnancy crisis centers and just anywhere where a woman may find out she’s pregnant. If she decides to continue with the pregnancy there is no time too soon of give the message of how much weight is appropriate to gain. And then we experienced a lot of resistance with the inadequate weight gain isn’t a problem, we show them the data, well that’s not in my practice, and a couple of our coordinators were really good at the how do you know and as Stephanie showed you with the ACOG flow sheet and then the grid, one of our coordinators developed that method in her trainings because they were just saying that’s not a problem so she would show up the ACOG grid and they would say oh that looks about right and then she would show the grid for the prenatal weight gain with the pounds, the one that Stephanie was talking about, and they would just be like, "Oh gosh".
You can tell immediately on that grid but that getting the people to fill out that grid is not an easy sell, because somebody has to fill it out. People loved the wheel, and we’d be millionaires by now if we didn’t have to do it all with state money and give it back. But the piece about working with providers on something tangible, what we had envisioned and a couple people did it was to work on these processor flow issues as kind of as a general topic. So when they would go in and do that practice assessment, since that grid is not the easiest thing in the most intuitive thing to complete, everyone wants a weeks and weight, not weight gained because then you have to do math, but, who is the appropriate person in the office to be doing this, where are they weighed and who does that and who’d make the most sense to be doing this task. And some of them did a really good job at working with some practices on that and a lot of them didn’t.
And this was what we had hoped because we know for real change to take place you’d need to have real concentrated, problem solving time and back to that whole quality improvement thing, is how can we do this so it’s not disruptive to you, so you can change your practice over time. So we were really hoping that they could try and start identifying, who does this, who does this, what order would it happen on a visit and try and really incorporate these into their daily practice. We found out that follow up with providers was extremely important. Originally we wanted them to follow up at three months and six months and I was like no way will that work, we need a follow up at two weeks, at one month, at three months and six months at a minimum.
Because the two week follow up is usually just a, hey how’s it going, do you remember that we had talked about this because people are really excited when the presentation for the most part. But that still doesn’t spark you to make any change, I mean, like all of us, we’re going to be at this conference and we’re going to get all this information, we’ll be really excited to go back do stuff and what are the chances that any of us are going to do anything different. So it’s kind of the same thing. But if you had somebody call you and say, you know you were at that session and maybe that’s what we’ll do, we’ll call all of you, and say you were at our session, and did you do anything, did you even talk to one person about it. But you know just kind of that reminder thing; sometimes will get you moving a little bit.
Then the other thing was, is not to get discouraged, this isn’t the easiest sell and as Stephanie was saying, people wanted us to kind of change the issue back to appropriate weight gain and I think Louisiana is going for the not too much, not too little, just right. But I like how you guys were saying, we marketed and tested this message, so we can’t change our message unless we change everything so were sticking with this message because that’s what we’re doing. Try new things, be creative, I think the grid, the ACOG flow sheet and the grid thing was a creative thing of showing people, you can’t really tell what’s going on here but this is such a visual thing you can see immediately the change here. And she got a lot of buy in with that because people were like, wow you can see immediately what happens. Plus a lot of women like to bring that kind of stuff home, so if you can give them a copy, some women will want to track where they’re at.
And we had built in all these evaluation tools, which we really didn’t talk about too much, but we really tried to merge and intertwine program and evaluation, so they had to fill out some, the coordinators had to fill out contact sheets and sign in sheets for training so we could count exactly what was going on and know even if they met the scope of their work. And we had built in these pre and post test quizzes which people hated, they hated them. Some of the coordinators could spin it a little better in more of a educational type thing, instead of a punitive quiz of we’re going to see if you know this, which was, I mean in hindsight is always twenty-twenty, but it was really stupid that we did this in some respects because we knew that people didn’t know what the weight gain recommendations were or anything about the issue in Colorado, so we were testing them for that and nobody knew, which we already knew that. And then we’re doing a post test after anywhere from a fifteen minute to an hour presentation, to show that that changed their knowledge or awareness somehow which is stupid because after an hour, who cares.
It really for us, it’s where the rubber hits the road, is do they do anything with the information, do they change practice and do they retain the knowledge. If we went back today would they know any of this? Probably not, maybe, though. So if you want to do something, don’t do quizzes. So Stephanie will talk briefly with what we’re doing now and if, we might have time, we can show you a quick demo of our website.
STEPHANIE BEAUDETTE: This is really what we’re doing, we’re just now starting to embark on a media campaign and we are smart enough to hire somebody who knows what they’re doing. There’s a social marketing firm in Denver that we’re going to be working with and they’re going to help us develop our messages for a media campaign and some collateral material and bring me up to speed with all of these other terms that I even learned a little bit more about today from Kelly and Allison. So we’re hoping to roll this out around Mother’s Day, it seems like a natural fit but given this is May, things don’t happen over night. Even folks who we’ve shared campaign materials with, as I mentioned our wheel, was our biggest hit and I’ve had several states call and say they want the wheel. And unfortunately we don’t have the funding to provide all of these materials nationally to people. Also folks need to modify them to meet their states needs, for example Wyoming , their rates are one in three women gain inadequately.
So we’re working with them on how can we help you guys get a graphic artist or whatever to adapt the materials, the brochures and that, so that it reads one in three Wyoming women instead one in four Colorado and sharing that information. But we’ve emailed the wheels and that to people nationally and they’re surprised to find out how long it takes to find a printer and to get these done and the cost associated with it. So we’re always looking for other financial resources, it would be great if someone would just give us a whole pot of money and say you guys just be the distributors, you know, nationally and make the changes and that and use the printers that you’ve already got, the connections established with it, certainly much more cost efficient that way. But we haven’t found that gem just yet. We do have a website, and again, this is always what was work in progress until my ad man, who’s a web developer, quit.
So we’re hoping to do some contract work with them, it’s pretty good, as it is right now and hopefully we can get this up and you can see a quick demo if your interested and sitting around for a couple of minutes. And just quickly about our collaboration with other states. I’m all for information sharing and not having people have to recreate the wheel, so to speak. So we’ve had requests for our materials from Vermont and again I mentioned the wheel that they had blown up to life size. I was also told that Blue Cross, Blue Shield in Vermont picked that up and was going to send it out to every pregnant woman through their Blue Cares program but I haven’t had that confirmation from my connection in Vermont just yet to see if that’s happened. Los Angeles and Sacramento County in California are using the materials and Los Angeles they're, can’t remember exactly what they changed the name to, Best Babies? But they added their logo onto the wheel as well as their 800 number for their programs.
Wyoming as I mentioned, I’ve had calls from North Carolina, Louisiana, Canada, couple of folks in Canada are using materials and trying to take on some similar efforts. So places that have been doing things and have shared information, their focus group reports from Louisiana I’ve had access to them and it’s wonderful for me to kind of see what their lessons learned are as well. So if anyone is interested in our materials or ideas, all we ask is that you send us something on your state letterhead that you’ll maintain our funding credits, you know our federal money and our MCH dollars on there. Colorado ’s logo, not to adapt the materials too much, then it doesn’t even look like ours but using the wheel or the grids or whatever pieces of information that you feel would be valuable for your state, we’re more than happy to share those with you. So at this point in time we’ll wrap up with, The Healthy Baby is Worth the Weight. We’ll entertain any questions you may have while Jodi gets the CD up and running. Yes.
UNKNOWN SPEAKER : I hope that this isn’t a stupid question—
JODI DRISKO : No such thing.
UNKNOWN SPEAKER : But I’m from Pennsylvania and we have a pretty bad low birth weight within the state and I’m just curious about how do you go about finding out the actual ratio or percentage of inadequate weight gain verses the low birth weight number?
STEPHANIE BEAUDETTE: And I don’t know if Jodi can answer this better than I.
JODI DRISKO : You guys aren’t a PRAMS state are you?
UNKNOWN SPEAKER : No.
JODI DRISKO : See with PRAMS it’s the easiest. I know in Wyoming , one thing they did, which a lot of people do, if you can’t calculate the BMI, because with just birth certificate, I think most people, you have their how much weight they gained. You can look at the proportion of people who’ve gained less than fifteen pounds. Which isn’t a good marker but it’s better then nothing. There’s also that study, which I said I was going to learn more about but since I just found out about it yesterday I didn’t learn anything more about it.
STEPHANIE BEAUDETTE: CDC has on their website, I just found this about a month ago and again, haven’t looked too much into it, I printed off the handout so I can look for Pennsylvania , if they’re on there. But they had in 2002, Pregnancy Nutrition Surveillance study and I don’t know the details but it broke down by state, the number of women who were gaining less then ideal and greater then ideal so I can’t look and see what Pennsylvania was. We need to look a little bit more into it, because, for example, I think it was New Hampshire or Vermont , had like 72% women gaining inadequately. And on some of the Indian reservations around us in Colorado not gaining upwards of 50% and 60% inadequately and that’s not what we’ve been hearing from the folks there.
UNKNOWN SPEAKER : What’s the name of it again?
STEPHANIE BEAUDETTE: It’s the Pregnancy Nutrition Surveillance Survey and I have it, I can give you the exact information.
Unk UNKNOWN SPEAKER : And it’s on the CDC website?
STEPHANIE BEAUDETTE: Yes.
UNKNOWN SPEAKER : (Inaudible) you were state here in the department of public health and the other states is it their department of health?
STEPHANIE BEAUDETTE: Yes usually the department of Health or Health and human services. Any area that’s working with maternal child health programs.
UNKNOWN SPEAKER : (inaudible)
STEPHANIE BEAUDETTE: Well with our coordinator efforts, our pilot with hit our seven largest counties throughout the state. We wrote each of our local health departments that received MCH money. We wrote a template and allowed them to choose that as one of their state plans for their MCH grant for the year. And so we’ve had maybe six more health departments pick that up, some are continuing on with their efforts, some are new, like the southern part of Colorado are, San Luis Valley is, Los Animos (inaudible) counties are very, very, very rural in fact most of their prenatal providers have left those counties and women are going to New Mexico for prenatal care and delivery. And yet they're still working on the campaign trying to find anyone, whether it’s a primary care physician and getting the information out to them, that if that mom comes in with a cold or a flu or brings their child in to a pediatrician or clinics setting, something else that those providers are informed of this campaign and weight gain can give supportive messages as well. So again, just trying to grass root, Jodi and I have done a number of conferences, public health conferences in Colorado this past year. And we’re hoping with our media campaign that we’re going to do some kind of mass mailing to all of our providers in Colorado, letting them know the media campaign is coming and what kinds of information or training would they like prior to that, to kind of get them up to speed. So I think we’re doing a pretty good job trying to get all corners of the state covered.
JODI DRISKO : Luckily, Colorado is square almost as interesting as Wyoming in shape and we have what we call the Front Range , which is the east side of the mountains. So these counties that line our Front Range, 80% of our population lives there and then the rest of the state is really very rural, so we’ve purposely started with the larger population centers. And we’re trying to hit the provider community first, to kind of give them a heads up of what’s happening before we roll out the consumer piece, because then if the women start going to the provider and say I saw this and they have no idea what they’re talking about, we’re going to get lots of nasty phone calls, more than usual.
UNKNOWN SPEAKER : Do you think that densely populated (inaudible) rather than the areas where you get the highest rate of low birth weight?
STEPHANIE BEAUDETTE: Yes.
JODI DRISKO : Out highest rate of low birth weight are some of the more densely populated areas but, some of the other little hotspots we didn’t pick to begin with because the numbers are so small.
STEPHANIE BEAUDETTE: And resources in that area are small as well unfortunately. Well here’s our website as it stands, again our address is WWW.healthy-baby.org.
JODI DRISKO : And it’s all messed up on the screen so, it actually does look a little better then that.
UNKNOWN SPEAKER : And the media campaign looks cheap and what does that, how many times are you having that? Is that radio?
STEPHANIE BEAUDETTE: That has yet to be determined, we have not even created the messages yet to test them and see where we need to go, because there’s going to be some parts of the state where, honestly, it’s going to be too expensive for us to run T.V. spots and we’re going to be better with just print or outside type, outdoor media that they were mentioning before. There’s other parts where it won’t be too expensive to do radio and that, I’m told we have a media buyer lined up who can get us 100% match, which means we pay for it, say 50 spots, and we end up getting 100 spots. And he’ll work with us in determining, you know, for this age group and for this group of women, here’s where we want to place these things or you’re going to get better bang for you buck by putting this in the Colorado Parents Magazine, that’s in all of the Babies R Us stores or Targets or something like that and hitting the market that way. So there’s a lot of unknowns and I’m just placing our information and money in those who, hopefully, can guide us in the best direction possible.
UNKNOWN SPEAKER : Do you think you’ll partner with some of the businesses (inaudible)?
STEPHANIE BEAUDETTE: We’re hoping to. But it’s yet to be determined, this is all, it’s in the infancy stages of where we’re going to go with this. So come May if you hear something then we were successful, if not like many other things in this state, I shouldn’t be upset if it’s not till next year.
JODI DRISKO : So I’ll just do a quick little overview. Sorry this is cut off something happened between the projector and this laptop that they don’t communicate well. But go ahead.
STEPHANIE BEAUDETTE: Here the women can go in again, most of the website is geared, the main front pages are geared towards the general public. And so on this site here the woman can go through and just do drop down boxes of height and weight and it populates the field with her BMI and then the categories are to it and the boxes to the right.
JODI DRISKO : This used to work a minute ago.
STEPHANIE BEAUDETTE: Well maybe if you’re only four foot and 130 pounds.
JODI DRISKO : I know but it actually computed it when I was testing it. This isn’t a live website (inaudible) this actually works if you go on the website.
STEPHANIE BEAUDETTE: I don’t know if we can scroll down on the page. We have on here an insert from the back of our brochure of where the weight goes, again with our teen population, we were hearing comments from our focus groups who have already gained 8 to 10 pounds, that’s more than what my baby weighs and when I deliver, so why do I need to gain the rest. So some of you might be familiar with these graphics already, or something similar kind of pointing out different parts of the body on the women where she’s gaining her weight. There is, at the bottom too, where the woman can print off and plot her own weight on the prenatal weight gain grid. We have web address on the bottom here, we’re hoping that maybe we can do some internet advertising, women kind find us themselves and take it into their providers and ask you know, what does this mean for me and where am I at.
JODI DRISKO : It has the instructions of how to calculate it.
STEPHANIE BEAUDETTE: We’ve got nutrition information materials, our brochures are on here, people can download them if they’d like. We’ve added on all of our WIC brochures that are available like in a Word document or a PDF that we can have electronically on here. On the health care providers pages as well, we’ve listed a couple of links to other reputable resources where they could purchase additional nutrition materials from either March of Dimes or American Dietetic Association, related to nutrition and pregnancy because we recognize that our brochure just hits the highlights. We just have enough information on there that the woman can go and talk to their provider.
It’s not going to give her every idea and every nutrition, snack and meal that’s high calorie, high fat, here’s how to eat, here’s how to do this, that and the other, because we wanted something that was easy and obviously it cost efficient to reproduce. Community programs and resources, we have this tab on here, again, it talks locally about how to get linked into the WIC program, nursing with partnership, prenatal plus, which is a case management program for high risk medicated women, which may not be our users of the web site. We have March of Dimes website, American Dietetic Association where you can find a dietician, you can just plug in your zip code and it will take you to a listing of dieticians and private practice in Colorado for that area, or nationally, who you could go see on an individual basis.
Smoking and pregnancy, we have some resources on here and it links to several other tools and programs that are nationally established. Ask the dietician, you can submit a question, myself or the other dietician in women’s health will respond to and will post appropriate questions as we can. And then our health care providers page links to information on the research, tools that they can use in practice, kind of glossed over the five A’s for weight gain counseling and pregnancy. We tried to adapt this to the five A’s that are familiar to smoking cessation during pregnancy and give providers a couple of tools with that. We did link on here our focus group reports, just specifically for pregnant women.
We didn’t think providers wanted to go and read about what they had already said; again I might get some nasty emails about that as well. And I can’t remember what else was on the provider page, reference materials, summaries of Medline abstracts or researcher reports that were produced either within the health department or nationally, you can link to the IOM reports. So there’s a wealth of information on here, there’s certainly a lot more that we would like to do going forward but it’s a start. Any other questions or comments anyone might have?
UNKNOWN SPEAKER : (inaudible)
JODI DRISKO : You guys are more than welcome to, if you want any of our materials to use them. As part of the Institute for Health Care Improvement, when I was doing quality improvement, one of their mottos was to steal shamelessly. So we offer you all to steal shamelessly.
STEPHANIE BEAUDETTE: Well thank you all for your time this morning, I know this isn’t the most opportune time, hopefully you all have time now in the afternoon now to do some sight seeing if you’re not from D.C., which I’m just going to load up on caffeine and head out and see everything myself. So thank you and our contact information’s in our presentation, it’s also in the brochures for the conference, as well if you want to call or email us. And also please fill out the gold evaluation forms and drop them in one of the several evaluation boxes placed throughout. Thank you.