AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
DEBRA BARA: Thanks, Lori. Can you hear me okay? I want you to know I appreciate you being here again on the last presentation on the last day. There's only seven slides left. Lori mentioned there were three cities that participated in the National Practice Collaborative. That was Orlando , Disneyland , St. Petersburg , where I'm from, and Jacksonville . And when we finished that practice collaborative we had an awareness that we really needed to have some changes in policy in Florida in order to do the things, that we sort of had intuition at that point we needed to do. And that was really focus more on the maternal health piece. All three of those cities had maternal health as our number one area where we had opportunity for improvement, and our intuition was that if we did this project with the other urban counties in Florida that we would have the same finding.
And in fact we had some evidence, because the Florida Department of Health had actually run this data several years before, back in 1998, and we were in about 2001, and we had some indication that that was true. The piece that we were missing, really, again, was the political will piece. Lori explained to you our Healthy Start coalitions actually have quite a bit of authority over our local communities. Florida statute gives us the opportunity to make, to do a lot of decision making in our local communities. And we're described as having oversight for the entire maternal and child health piece, but we operate within the Florida system of care, and we have what we call standards and guidelines, which are our policies and procedures. And some of those really sort of were roadblocks for us for doing some of the things we needed to do.
So the Healthy Start coalitions in Florida are sort of famous for plotting social revolution. When you get all of us together and we start having our little thinking parties about what we need to do, we come up oftentimes with strategies and what we tried to do was develop a strategy to build that political will. So we knew we needed to expand the knowledge base in Florida . We had about, between nine and 12 people in Florida at that point that really understood at a deep level PPOR, how to do it, what the opportunities were. And we knew that we had to have a larger group. And as Lori mentioned, our strategy was really focused on influencing decisions and building capacity throughout Florida , not just those three cities, to bring about change. And Karen mentioned that she saw PPOR as a planning tool. And I think it's an excellent planning tool. But I actually think it's about change, and that's what we ultimately wanted to see.
So we knew we wanted to partner with the March of Dimes, as Lori mentioned. They've been a great partner to us for many years. So the three cities wrote a proposal to the March of Dimes. And in that proposal we approached the seven largest counties in Florida . And I've got the communities listed here. That's Miami‑Dade, Fort Lauderdale , West Palm Beach . Orlando , Jacksonville and St. Petersburg had already been in the previous practice collaborative, and we added Tampa to that group, which is right across the bay from me.
And we knew we needed to engage Florida 's Department of Health, because that was really the body within Florida that established the policy piece that we knew needed to change. And those seven counties accounted for about 60% of the births in Florida . So we knew again that if they all came out with maternal health as our primary opportunity for change, that we were on the right track in terms of being able to make systemic changes throughout Florida , because those seven counties drive the data for the whole state.
So what we did was we met for a year. We had four meetings in a year. And we met with those seven counties. And the March of Dimes funded this as an educational opportunity and we essentially taught those seven counties how to do PPOR, and then we really spent most of the time looking at what were the results. And we knew that we needed to really refocus our whole maternal and child health system on the maternal health cell in the PPOR model. March of Dimes had come to that conclusion. They had started their prematurity campaign, and we had all been looking at the rising rates of prematurity, and we knew, given the context that Lori described to you about what was happening politically, we were not going to have any money to do this. We knew that whatever we proposed, we had to do not only within existing resources in many cases, but within declining resources. So we also knew that what we were doing wasn't getting us where we wanted to go. We had seen a big decline in infant mortality rates over the past decade. We had dropped about 22%. But we also were watching that rate slowly creep up and we had seen increased rates in very low birth weight and low birth weight and prematurity. So we knew that our system of care wasn't getting us where we wanted to go.
This again is the model that you're all used to seeing, the blue box, maternal health is where we really wanted to be, and what we found, when we looked at our system of care, was we had focused quite a bit on those bottom three boxes, and maternal care newborn care and infant health. Back in the early 1990s we had expanded Medicaid reimbursements to OB/GYNs so we didn't have the problem that Ohio had with prenatal care. We actually had very few people who weren't getting prenatal care. And we had pretty good rates of utilization, and we had a way to track that on our birth certificates. We used the caudal check system and we didn't really have a big issue with that.
We also had a great system of high risk OB care. Our children's medical services. We had good referral systems in place. And we had regional perinatal centers of care. So we had a pretty good healthcare system. And our Healthy Start services actually begin at the point of pregnancy. So our system of care is that once a woman is pregnant, we have our universal screening. When she shows up for her first prenatal visit she gets a Healthy Start screen and it tells us who is high risk right away. We can get them into psychosocial or clinical care services. So that piece we were doing pretty well on. In newborn care, of course, everybody knows, and I have to mention the March of Dimes, surfactin has made a huge difference in the survival rates we had a great system of newborn care and the advanced technology, we had a pretty good survival rate there. Indeed, in some of the communities in Florida we did not see health disparities within those two cells. We could actually see, and that gives me great hope that there's actually a way for us to reduce health disparities, because in several communities that was happening. And then the infant healthcare was really where our Healthy Start services had focused quite a bit of attention. We did lots of programs for back to sleep campaign, child safety programs, car seat programs, all of those kind of things. That was actually our second highest cell for most of Florida . But the maternal health piece we saw no programs really going on there. And the way our system of care was set up in Florida , you got Medicaid if you were very, very poor and about 50% of the births in Florida are funded by Medicaid but that drops off right after the baby is born. Mothers don't necessarily get back into care. So we had, and we have a high rate of people with no insurance. So we did not have a great system of care right there.
So what we wanted to do was to gain consensus with our partners, with the March of Dimes, which is major advocacy work, our county health departments, our Healthy Start coalitions, our FIMR projects and Department of Health, so we could take that energy and refocus on the maternal health piece. And one of the big things that came out of this was our recognition that we were not going to be able to provide healthcare services for women of child bearing age throughout Florida . We just didn't have the resources to do that. But when we started thinking about our policies one of the things that really jumped out at us was in Healthy Start, if a woman had a fetal or infant loss we closed out services to her within six weeks. Which, in the context of PPOR, made absolutely no sense. So we asked the state of Florida to work with us on redesigning our policies. And one of them was we developed an interconceptional care model and we did that based on the March of Dimes work on prematurity, and came up with ten focus areas. And basically changed our whole system of care for Healthy Start to say if you are a woman who has a risk factor and the Healthy Start program has services to offer that woman, that she could receive that service whether or not she had an infant. So it's not preconceptionnal care because we're not able to serve them before they come in, but I think as it was Karen that mentioned about the women who have high risk pregnancies, we can now serve them up to two years with things like smoking cessation services, alcohol, drug treatment, things like if they have mental health problems, they can remain in our system of care. And that was a huge end result for us.
The other thing was educating our MCH partners around the state on disparities in the area of the maternal health and preconception care. That was where our biggest gap was, and it really helped us to refocus so we have lots going on on racial disparity right now in Florida . But it really helped us to refocus our attention on what we really need to do is find those women before they get pregnant.
So, for example, in my community, our health department wrote a STEPS grant that's all focused on chronic health ‑‑ I mean chronic disease prevention, educating people about exercise and nutrition, and we really have a lot of specialized components that are for the women of child bearing age that are not pregnant and have never been pregnant.
And we had to start thinking beyond just prenatal care access and quality and really start expanding our influence and developing some partnerships with people who serve women before they get pregnant. The March of Dimes summit finding was also that much, we needed a much stronger focus on interconceptional and preconception health and they've been a great partner to us in trying to do that, because really within our Healthy Start system of care, we don't have the ability, still, at this point to do that. So some of the things that are coming out of it now, and many people mentioned, it's like one level after another of who do you talk to and another set of data analysis, and the direction that we're moving in now is really trying to develop some relationships in our local communities with the community health centers. We have four in my particular community and trying to connect with them. We haven't connected much before because we've only connected in the arena of OB care. So now really starting to talk to them about, will they implement screening instruments for women who are not pregnant to identify those components of lifestyle or psychosocial needs that might contribute to a poor pregnancy outcome before they get pregnant, or ask them, were they themselves premature, have they had an infant or fetal loss before, just ask those questions when they come in for care so that we can begin to implement services and initiate services to women that might be at high risk before they get pregnant.
And developing relationships with primary healthcare. We're talking about in our community the whole topic of adolescent health, which we've always been somewhat involved with, but now we have a deeper understanding that many of the bad behaviors or difficulties, things like smoking, drug use, eating disorders, mental health problems often we can identify those and know who those folks are that are at risk for those kinds of things, when they are teenagers and we don't have great strategies in place right now linking that system of care with the maternal and child healthcare system. So we're looking at how might those partnerships be developed, talking about things like placing staff in pediatricians' offices. Right now we have them in OB offices, but placing staff in pediatricians' offices to develop more a broader system of healthcare.
Was there ‑‑ I wanted to talk a little bit about ‑‑ why don't you talk about that, Lori, the March of Dimes?
LORI REEVES: One of the other things that developed out of the Perinatal Period of Risk analysis, and the focus on preconception health, the March of Dimes has been doing (inaudible) for many years I've been with March of Dimes for ten years (inaudible) then became a (inaudible) campaign. A couple years ago Florida had an opportunity to apply for funding with the Attorney General's Office for money from the National Vitamin Settlement. We were fortunate to receive a $2 million award to do a vitamin distribution project for underserved women of child‑bearing age for a two year period of time. After we looked at the PPOR data and looked at the focus that needed to be on preconception health, we talked to the state health office and came up with the idea to place the project manager provide a grant in the state health offices, March of Dimes employee but working within family health services so that they could become linked with all of the programs that provided services to women of child‑bearing age, including family planning, with a preconception/interconceptional health focus. They would go out and not just be speaking about vitamin distribution and the importance of taking folic acid to be healthy prior to pregnancy but also the other preconception health messages.
So this is the first position of its type there. It's a brand new partnership and we're very excited about it, and the state health office is very excited about it. It's a whole new opportunity.