Sunday, October 19,2003

1:20-3:00 PM

Maribeth Badura: Thanks. It’s great to be here with you. It’s a wonderful bright day and the sun coming in. I want to make sure you all stay awake this afternoon, you don’t get that post lunch sugar low, so let’s get started. The Division of Perinatal Systems in Women’s Health has a responsibility for the programmatic activities related to woman’s health, and we really conceptualize that across the lifespan with an emphasis on women of reproductive age. Our funding for our division comes from two sources: one, the Title V Block Grant, but the second program that we have administrative responsibility for is the Healthy Start Program, which is funded under the Public Health Service Act. It was authorized in 2000 as part of the Children’s Omnibus Bill. The division activities, again, covers the lifespan, but they also have a span from health promotion to risk reduction-risk prevention, and all of our grants and work at this point focus somewhere along that continuum also. All the grants and activities have an infrastructure-building component and all the programs involve women, their families, and communities. So we’re really trying to take that concept of family centered care and move it into the realm of what do we want for women? In the risk reduction prevention area, we have a number of programs that we’ve been working on over the past five to six years. We’ve recently completed a series of four alcohol-screening programs. Those programs were to identify methods in which to improve provider screening on alcohol, and we refunded in a limited competition two of the projects to go ahead. We had some very, very good findings about how to have providers actually screen more, record what they were doing, and find simple questions that were important, and we funded in Illinois and Massachusetts a replication to see whether what they learned in one side in their state could be transferable to another. We’ve had, again, for about a six-year period, an emphasis on family violence screening, and that also is a systems development activity to make sure that the linkages with welfare, with the justice system, are in place. The perinatal depression screening is a newer focus. It started in 2001 and it’s a focus of all 96 of our Healthy Start communities to fund individuals, find them in the community, see during the prenatal period, the postpartum period, and screen them for depression, referral, and if necessary, treatment. Because of the work we’re doing in screening, we also realize that you’ve got three different screening tools here and so what we’re trying to do is what I know some of you are also trying to do at the state level, is look at what are the pivotal questions? If we take one or two questions from alcohol, one or two questions from family violence, some questions from substance abuse, some questions from perinatal depression, are there key questions in any of those screens that we can narrow down that we would have sort of a one stop screen and then you would go further and identify what other areas would need further assessment. So to sort of simplify the screening process, we have funded three multiple risk screening projects. They’re just starting at this point. And then in substance abuse and smoking cessation: Healthy Families America and some work with all of our communities across the United States on identification of substance abuse. In the infrastructure area we funded, now we’re going to be funding this next spring six more grants, but we have an integrated women’s health structure infrastructure program that will be a total of 12 states currently funded with six more states coming on. So a total of 18 states will be funded for this activity, and the purpose of this activity is to bring together all the necessary parties at the state level and at the community level that need to be involved in a comprehensive woman’s health program. Similarly, we’ve also funded the state morbidity and mortality review programs and those covered either child fatality, maternal fatality, or infant mortality review programs, and those programs are getting into their final year at this point. We have a competition upcoming in women’s behavioral health systems building, again to bring together all the players that need to be at the table and to activate community and local groups in the mental health community and bring them into the MCH community so that we’ve got again a comprehensive system for women. We have a National Fetal Infant Mortality Review Resource Center at ACOG, which I’m sure many of you are aware of, and we have just funded the National Healthy Start Leadership Training Center, which will be holding six regional workshops across the United States, and I know that many of you in your Title V programs are very involved and will be involved in some of these workshops. The region six folks just had their meeting in Las Cruces, New Mexico this past week and this really is to develop the leaders in the Healthy Start community and begin clearinghouse activity on best practices. In the health promotion area, we do have a program that we’re very excited about; again, a new competition funded in the spring. This one is on innovative approaches to promoting a healthy weight in women; it’ll really deal with the issue of obesity and what services need to be available, what’s the best motivating factors to really engage women in this necessary area. And then our final activity is breast-feeding education. Just generally we all know there’s a gap, in African-American community in particular, in both the duration and even initiation of breast-feeding. So we’re going to be working with the Office of Women’s Health at the secretarial level on a campaign on breast-feeding education. We also, as I said, have a responsibility for the Healthy Start program. Currently that program is in 37 states, the District of Columbia, Puerto Rico, the Virgin Islands, and covers about 42 indigenous populations, Native Americans, and Native Hawaiians. The Healthy Start communities are funded in four areas currently. The eliminating disparities and perinatal health, a special focus on the border, Alaska and Hawaiian areas, and in those two programs we’re beginning a cycle for the next three years in which we will have a rollover of funds and new competition. This is sort of a heads-up to you. We have a small competition this coming year. We have about $6.1 million; next year we have close to $80 million that will be turning over and will be up for open competition. About $9 million will rollover in 2006, so if you have pockets of infant mortality in your state, you know, keep this on your radar screen because the notices will be coming out soon, and as I said, this is the start of a three-year cycle that we’re going into on refunding of these programs. When we funded the disparities programs, a series of six grants who focused on high risk interconceptional care, and those particular grants looked at women who perhaps were not in the care system who had a fetal loss, who had a high risk pregnancy, or who delivered a high risk infant, and we have a special case management outreach program for six grants in those areas to really develop the system for that particular group of high risk women. Overall, because of where the Healthy Start communities are located, the average infant mortality rate for any of the communities, the threshold is one and a half times the national average, so you know that we’re in the poorest communities and many of those women are high risk, psychosocially. But these are some of the highest risk women and we want them followed through the first two years after delivery and until the baby’s second pregnancy to see if we can minimize a negative outcome in the second pregnancy. And as I indicated, we also have all of our projects screening for perinatal depression, but we did fund eight special grants to look at not only the perinatal depression but the systems that need to be in place for that depression. In addition to those particular clusters, 29 of the disparity grants received over a million dollars and those projects also have responsibility for the systems development in the area of perinatal depression and high-risk interconceptional care. What we’re looking forward to as we begin the cycle of recompetition, we’re also looking forward to one of the best things that you learn in any service program, and that is what’s working well, what are the best practices that we can share with the rest of the MCH community, and so as these reports come in, we’re going to be pulling those best practices and trying to summarize them under a variety of topics so that we can get those out to you. What are, you know, the most effective smoking cessation programs? Which programs have a very good outreach system and what are those elements? What are the protocols that are necessary for case management? And probably the thing that we’re learning the most in this, what are the services that a woman needs after delivery and for the first two years following that delivery? When should we be making home visits and what are the contents of those home visits? The core services for Healthy Start emerged from our demonstration programs and they were outreach, case management, health education, screening for depression, and then what we call interconceptional continuity care, and just like we believe that every child should have a medical home, we believe that every woman must also have a medical home. So part of the interconceptional continuity care in the charge of the Healthy Start projects is to insure that that woman has primary and preventive services from the time that first pregnancy test until two years following delivery. We really want to make sure that she gets the screening and referrals that she needs. We also have some very strong systems building activities, both consumer, and that we mean women participating in the program should have a say in what the practice settings, the policies, are about the services they’re receiving, and a consortium composed of all the key stakeholders in the community, businesses, faith based groups, coming together and tackling some of the issues to make that system at the community level work better for families. One of the mandates in the Healthy Start legislation, as I’m sure you’re all aware, is there’s a requirement for collaboration with Title V both to make sure that the individuals in the program have the necessary services because Title V is--that’s our core nucleus from which we build, but also to make sure that--and we can also share with the Title V program and they can share with their Title V programs what’s happening in those communities and what are the best practices in their state. And then finally, sustainability, making sure that they’re engendering federal funds to continue the work after our program would leave, but also institutionalizing in the communities elements of the program that are successful. In terms of women, their families, and communities, all of our projects require cultural competence and they have a performance measure similar to the one that you use to mark their progress on cultural competence, areas that they need to go. They also require family involvement and again it’s a very similar measure to what you also are examining when you do your measures on performance. We involve also one of our partners and that’s that Healthy Mothers, Healthy Babies National Coalition, which I’m sure you’re all familiar with. We also have responsibility with Dr. Van Dyck on the Advisory Committee on infant mortality, the HHS Interagency Coordinating Counsel on low birth weight and preterm, which is a federal group bringing together all the research that all federal agencies are doing on those two areas. We work also as part of the federal interagency committee on safe motherhood and two activities there. We just had with AMCHP a meeting in which we brought in states that were working on maternal mortality reviews with CDC and really tried to identify the best practices that were emerging in the area of maternal mortality reviews. And the second area that we hope to have a publication out that we’ll share with you in May is an area, we commissioned an evidence based research study out of ARC on perinatal depression looking at what are the best screening tools, what are the most effective interventions, and we’ve just received the preliminary report on that. When all the federal agencies got together, that was the one area that everyone agreed was an important area that we needed to examine, so that’s the first activity out of that group. And then finally, we fund the National Hispanic Prenatal Hotline, which handles the Hispanic calls that do not roll into your Title V programs. And that’s actually my presentation. Any questions?

Unidentified Speaker: Yes. You said the beginning of the Healthy Start funding cycle is going to be a three-year cycle? I’m brand new to the department. Can you give me a little bit more information on that?

Maribeth Badura: Sure. We’re awaiting the guidance to come out on the street for the first part of the cycle. What I meant when the cycle was, we fund the grants for four years when they’re funded, and so we have some that will be, as I said, rolling over. Projects can ask for up to a million dollars, they must have a consortium, they must have collaboration with Title V, and they must have an infant mortality rate that is above 10.5 unless they are coming in from the border area, Alaska or Hawaii. And then we have some other criteria that we’ve identified because of some of the difficulties in getting true measures of infant mortality with those populations. So when the guidance is then out on the street, you can expect after this guidance is out that the guidance probably will remain pretty much the same for the next three years. So if you have communities that might not be ready this year, you’d want to look for then the next year and then there’s a final year in 2006. Does that help?

Unidentified Speaker: Yes. Is there a website that I can go to?

Maribeth Badura: If you go to the HRSA Grants website and you click on--they have a listing of all the programs there, or you can go to the MCH gov website and it’ll crosslink. But if you go to HRSA Grants website and just click on where it says “HRSA Preview 2004,” that’ll take you to all the grants that are available. It’s a real good place just to watch and it’ll sort of tell you what the due dates are and when the guidance will be out on the street. And there are some things that you can almost do right now to set yourself up so that when guidances come out there’s some preliminary activities that it sort of walks you step by step through of what you need to do. This year we’ve been informed that we will be testing--not only will people be able to submit their application electronically, but the federal government has an e-government initiative, which is a web based application, and Healthy Start will be one of the programs that will be on that e-gov web based application format. So it’s going to be a new adventure for all of us. There was another question. Yes?

Unidentified Speaker: I just have a short one; it’s just yes or no. Is there a comment period on the guidance or is that (inaudible)?

Maribeth Badura: What do you mean a comment period?

Unidentified Speaker: Is there an opportunity to make comments on (inaudible)?

Maribeth Badura: No, actually, once the guidance is out and it’s going through--then it’s officially the guidance that is used for the competition.

Unidentified Speaker: And the second question is, has anyone looked at the outcomes of these projects in terms of infant mortality and are they different from the, you know, the general statewide figures?

Maribeth Badura: We actually have had some very dramatic successes in many of our communities in terms of participants and in terms of overall reduction of infant mortality in the community, and I know in the state of Illinois and in the District of Columbia, though the District is a little harder to say because we cover all the wards except for one, but in portions of New York, the communities right now are indeed below the statewide average in some areas. So we are seeing the success, but it’s not something that comes in a short time period. I think most of the grants that we’re seeing that movement on have been funded for at least six to eight years, so it’s been two cycles at least, but we are seeing results very definitely. One of our projects in Des Moines, Iowa, for example, has not had an African-American death since 1997 in any of their participants, so some very good results that are coming forward. We do have a national evaluation that we are in phase one and we will be collecting data for the first year for calendar year 2003. So we’ll have more to report as we begin looking at the impact of this last cycle. Anything else? Thanks.