AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
CAROLYN SLACK: Good morning. Thanks for hanging in there. There are a couple more seats up in front if folks want to come and sit down because it can get kind of tiring. I'm thrilled to be here to talk about what we are doing, what we learned in Ohio . And in terms of capacity building, I couldn't think of a better word to describe what we've been doing better than capacity building. Not only for our data system, our systems of care, but policy initiatives. And we've got lots of stories to tell about all of those but I'm probably going to mostly talk about the system of care issue and some of the policy initiatives work we've been doing. We were one of the first cities to be part of the national practice collaborative, and we had some very early and important lessons that we learned quite a bit from and shared quite quickly with my state partner here, Karen Hughes and I have worked on this since I first heard about it and went back and told her about this really cool thing. We had a lot of early work to do around our data. When bill Sappenfield put together the national data tables, he would put up what I would call the Ohio slide of shame in terms of between Cincinnati , Cleveland and Columbus they were the highest rates of missing data. He was using the NCHS linked birth and death certificates. Ohio at that time did not do linking but was depending on NCHS to do that linking and we learned so much when we had to build our own data set within Franklin County, found there were missing deaths, the data that was missing on the NCHS tape we had because we were looking at the hard copy birth and death certificates so some real issues along the data quality piece. And in the meantime the state health department does do the matching of the birth and death certificates but we're still working on some of that missing data piece, which is still not making a lot of sense to us.
We were able to use and integrate PPOR into many things within Columbus and Franklin County and it was exciting to share that very quickly with the state. As part of that, we did mini presentations in the beginning like through our Ohio public health association and Karen invited us to the state health department to present to the state's birth outcome group. So that was the first entrée into the state folks who got very interested and they were hooked as quickly as we were hooked to begin some of that work.
What we learned we did all the stuff that Jenny just showed you, all the phase one and phase two. We've got a very strong epi component within our health department . We have five full‑time epidemiologists and a couple of folks who are really interested in MCH so we've had some very strong support for doing that. And to cut to the chase, what we learned, which shouldn't be any surprise to anybody in this room, the persistent racial and ethnic disparities in terms of the outcomes. We also found that for our African American moms, two areas popped up: The maternal health and prematurity piece and the infant health piece. Actually, for the first time period that we looked at, infant health exceeded maternal health, which was a surprise to us. And we did that secondary analysis that phase two piece, the SIDS death rate was like four to six times greater within our African American population. So again there's a whole other story I could talk about the community initiative that took off as a result of that.
But, again, actually for all populations and again for African American moms in both time periods and in the second time period we looked at, the women's health and prematurity was clearly the place that popped out. Within that, when we did that phase two analysis and took a look at what were some of the significant risk factors we saw that popped up inadequate prenatal care is the piece that popped up for both of those areas, but again we were focusing on the women's health piece and the prematurity piece.
So from knowing to doing: I've heard a lot of talk about braiding of funding. I'd like to talk about our PPOR approach as more of a braiding of efforts. We have a lot of different initiatives going on within our county and city, and one of the greatest ones has been work through the Council on Healthy Mothers and Babies, which is a collaborative relationship working to address infant mortality. One of the things that the council on Healthy Mothers and Babies is very interested in is prenatal care access. So when we started integrating our findings from PPOR to that particular group, they really latched onto, well, inadequate prenatal care. This braids well with all the work the council has been doing in terms of tracking women's access to prenatal care. So we just had an excellent opportunity then to take off, and this really became a push for the work that we could do around addressing prenatal care access.
Again, what I want to talk to you about then is what that story I'm going to drop in here the middle of this presentation this story of the work we've done around prenatal care access.
We've worked to educate the community and stakeholders and lots of folks and have put together a lot of information to take folks through the whole story about why prenatal care is important, and one of the interesting just side lights that we learned in this process, when we had one of our major round tables last fall, was that we still have to make a case for prenatal care. For us in this room it could be almost intuitive that prenatal care is probably a good thing, but there's folks for whom we need to say why is it a good thing? What difference does it make? Why is it an important piece. Having to do that we need to do more work on that and we learned that as part of this whole process.
So in terms of working with a community and our stakeholders, we took a look at what our PPOR data said, validated prenatal care as a problem. But, again, we went back and integrated other data. We took a look at more vital statistics data. We talked about PPOR, did some surveying, some key informant surveys around the prenatal care access. I'll run through them quickly. Again things that wouldn't make a surprise to most folks in terms of access to prenatal care in first trimester: We have racial and ethnic disparities, not only within this state but within Franklin County , which is the county which the city of Columbus sits.
We also took a look at the percentage of women with no or unknown prenatal care. Again, we continued to see, again looking at our vital statistics data, racial and ethnic disparities within that information.
We then talked again when we were talking with folks about what did our perinatal periods of risk, we took the opportunity to explain what that piece was about and the work of other community organizations around this. But, again, within the council, this has become something that the council members talk about pretty regularly. Well, you know in the perinatal periods risk analysis this is what we learned there and that's why we're working on this particular issue. So, again, affirming the results of those findings.
Like most counties, our infant mortality rate overall seems to be going down. The persistent racial and ethnic disparity continues. One of the things we've done internally is we did analysis of the trend line between '79 and 2002, and what we discovered, the disparity in our community is increasing. While the overall rates seem to be going down, the disparity is increasing. Again, this s critically important information to inspire action around this and to really engage some of our political partners, particularly the city council member who is the chair of the Health Committee for the mayor's office or for the city council and for Columbus.
One of the things the Council on Healthy Mothers and Babies does is a survey about entry into prenatal care. What happens is we have a person who calls all of the hospitals. We have seven hospitals that do outpatient obstetric care, our neighborhood health centers, there are six, and our Columbus health department, which has two sites at that time. Every time she does this, she writes down how many days does it take to get a first prenatal care appointment and does the average of that. Actually, we had one done in December but the slide, we just got the information so I couldn't incorporate it. In December the waiting time was 22 days. We have a long range of how many days women wait for prenatal care. And the other thing we have going on in our community are a number of providers who, when this person calls to make the appointment, says well we can't take any more appointments, we're booked so far out. And the last time the December survey, that was both sites for the Columbus health department, we were already at four weeks. So after that we just say well we can't take anybody in. And they need to call somewhere else.
So, again, this is something that's been going on since the early '90s, keeping track of this.
Here's kind of a ‑‑ not kind of a graph ‑‑ it is a graph ‑‑ of what those wait times look like. And I didn't need to have anybody do a trend line for me to say gee how does this look, is it going up and down or staying the same. Again, overall, we're seeing it increase in the number of average number of days that somebody would wait to get that first prenatal care appointment in our community for what I would call the public providers, again, the hospitals, the health centers and the health department.
Another thing that was a positive piece that had been going on as part of the prenatal care capacity issue was an incredible partnership among, again, the providers I just mentioned, hospital, health centers and the health department in terms of putting together a one telephone line that women could call to schedule a prenatal care appointment. And it took us about a year to work on that as a community, because we were asking all the providers to give up some slots to the telephone line so women would call this one line they could get into an appointment much quicker. And we were able to open that line in August of 2003.
Prior to doing that, during that work group, we wanted to figure out, well how many appointments do we have in the system? This first prenatal care appointments, how many are we playing with? So overall, when we did that analysis in May 2003 of all those providers, we had about 1500 slots. Well, we opened the line and for a while the women calling Pregnancy Care Connection were getting in much much quicker. But after a while those times started to creep up. In fact, in our last survey, the one I just mentioned in December, if you call directly to a provider, you're waiting an average of 22 days. If you call Pregnancy Care Connection you're waiting 20 days. We said what's going on here this is not happy news. So we did another capacity analysis and asked everybody, okay, how many slots do you have? What's going on here? And we discovered we're down to a little over 1100 slots. So about a 31% decrease in prenatal care appointment access within the community among those providers.
So that's when we stepped back and did this key informant survey to find out what's going on there? Well, what we found out for the Columbus health department is that part of our, what we call our (inaudible) health service funding which is the code word for Title V. It's not all Title V but everybody understands Title V. Is that okay? The Title V funding, to local providers over the last five years had decreased 27%. For the first couple of years we could sort of suck it up and not really have to do anything to our capacity, but finally, in '04, we did have to close one of our sites on the west side and then this year, with the reduction again we had to let go one of our providers.
So, again, that's why our capacity within the health department had decreased. We then took a look at what was going on with our neighborhood health centers. Our city funds the neighbors health centers and they also get some federally qualified health center funding. But, again, hard times have hit us all. So two of the centers closed, or actually consolidated. But what happened ‑‑ and I'll use the names. St. Mark used to have eight hours of prenatal care and St. Stephens had eight hours. When the two centers consolidated, there was still eight hours of prenatal care. Again, that's where we lost capacity.
When we talked with our hospital partners to say, what's going on in the hospitals, one of the big things affecting the hospitals was the change in the residency laws, which says that residents couldn't work more than 80 hours a week. Well, that's reasonable. I can understand why they wouldn't want to do that. But where mostly they took the hits were in all of the outpatient departments. So, again, that's why the loss of capacity at the hospitals.
So, again, way back in PPOR we saw this pop up again but it led to all other kinds of looking at data and trying to figure out what's going on, what's the story here. Braided into our current efforts.
Other things going on: We've had a great migration into our community of Hispanic moms and actually Somali families. Where you're providing services to people for whom English is not even a language much less a second language and you have interpreters involved, those appointments all take much longer; therefore, you can't schedule as many people in that you would normally see because of the interpretation piece. So that affected capacity.
Then the other big elephant in the room that's sitting out there is the whole issue about the liability and malpractice around obstetricians gynecologists. Our newspapers, as many of yours might have done, full page ads of OB/GYNs who are no longer providing services. There was incredibly powerful sad lesson that occurred that the chief of staff of our mayor's office, his wife had to change obstetricians in mid‑pregnancy because her obstetrician was no longer going to be doing prenatal care. We were able to use that as kind of a story. The message we talked about, if we're finding women who are well insured are going to have problems accessing obstetric care, the trickle down effect for women who are uninsured or on Medicaid is going to be exponential. We had all this information we could pull together.
So what did we do? We pulled together a major roundtable last fall that was co‑convened by our city council woman, and we had worked ahead of time and brought in a lot of folks who we thought could help us make some important decisions and put together a number of strategies. In addition to wanting to address access to prenatal care and all that has to go around that, the overriding, the big issue also is health of women. So part of our strategy, in terms of increasing access to prenatal care, was to think about a family planning waiver, in terms of being able to ‑‑ and Ohio is one of the states, after 60 days moms lose their Medicaid coverage. And what we're discovering through all of our services and what we know through the PPOR that the issues of women's health are incredibly important. So the council was very interested in that. Unbeknownst to us at that time, but there was some interest about another group in Ohio that's interested in family planning waiver and the state health department was starting to have those discussions so all of a sudden we've got this convergence of folks interested in pursuing this piece of it going forward with that waiver. We've had some really good news in terms of the mayor put in his 2005 budget money for us to reopen that west side prenatal care clinic, and that was just unexpected miracle. I still can't believe it. But it really did happen and it passed city council. We've got strong support for that. The response to the data and information, and I've got ‑‑ we also got incredibly good media coverage out of this. Front page coverage for this issue. So that really helps too and our mayor wants to run for governor. So I guess this is good.
Anyway, the health centers, through another major initiative about access to care in the community, because of the work we've done around their prenatal care, got funding to add two more sessions. So, again, other good news there. We got great media coverage. Then one of the things that happened, this is a lemon to lemonade story, which we hope it won't become lemons again, is some changes at the state level in terms of focusing women's health services funds and I think maybe Karen, I don't want to take Karen's story, but I think one of the thing that Karen thought when she had to make this change, what she knew now about preconception health and women's health was really able to make a great lemonade. And we now have some funds which our department applied for which does provide family planning services so all the moms that we were seeing within our prenatal clinic we serve about 1150 women a year, were able to maintain their healthcare afterwards and do that family planning piece. All of that will contribute to mom being a healthier person.
So we've had some pretty powerful stuff going on as a result of this. We just had our last meeting just Friday. So we haven't had a chance to update the slides, but we've got some real folks, very interested in the family planning waiver, what we call the power folks who could make a difference, so we're excited about where this could lead, and it all trickles back to what we learned through PPOR as a community planning initiative and also another validation of the kind of work that needs to get done. Part two.