a neighborhood network of care for pregnant women and...
TRANSCRIPT
W O M E N ’ S H E A L T H P R O G R A M S & I N N O V A T I O NL O S A N G E L E S C O U N T Y D E P A R T M E N T O F H E A L T H
S E R V I C E S2 / 1 2 / 1 9
A NEIGHBORHOOD NETWORK OF CARE FOR PREGNANT WOMEN AND FAMILIES
Introductions
Dr. Erin Saleeby, MD, MPH
Director of Women’s Health Programs & Innovation
Moraya Moini, MPH
Program Director, Strong Start Initiative – MAMA’s Neighborhood
Dannelle Pietersz, NP, MSN, MPH
Family Planning Clinical Programs Manager
Dr. Ashaki M. Jackson, MFA, Ph.D
Research and Evaluation Portfolio Manager
Brandi E. Sankey, MPH, MS, MCHES®
Health Educator, Baby Boutique Program Manager
Strong Start - MAMA’s Neighborhood
M – Maternity April 2013 - Los Angeles County Department of
A – Assessment Health Services (LACDHS) Division of Women’s
M – Management Health Programs & Innovation established a
A - Access and new, strategic platform of comprehensive,
S – Service synergy coordinated and continuous care for women and
throughout the their families.
Neighborhood – for CMS funded program focus is to improve
Health pregnancy and birth outcomes by addressing
social determinants that impact rate of preterm birth
and low birthweight.
Women’s Health Programs & Innovation
Comprehensive Women’s Health Services at DHS include:
Well-Woman Care
Prenatal Care
Family Planning
Specialized Obstetrics & Gynecology Services
Primary Prevention
Services are provided to women of all ages and stages in life.
Model & Care Domains
CARE DOMAINS
1. Substance Use
2. Social Support
3. Mental Health
4. Biomedical
Risk
Maternal-Centered Medical Home
Patient registers with DHS as their maternity home.
Initial clinical and social care assessment to identify strengths and areas of improvement.
Multi-disciplinary team of clinical and social care professionals coordinate care, and connect/link patients with Neighborhood Network pathways of care.
Uses evidence-based measures and quality indicators to aid in continuous quality improvement activities.
Utilize electronic health records and empanel mothers to support continuity of care, and identify strengths and gaps in care.
Offer proactive clinical and social care teams that honor perinatal period as critical a window for intervention and improvement, and special time for mothers.
Team Services
Care Coordinators
Maternity mental health providers
Social workers
Health Educators
Doctors
Nurses
Nutritionists
Community based organizations and agencies
Prenatal Education and Resiliency Classes (Fathers included)
Housing assistance
WIC and other food services
Substance use treatment
Childhood education resources
Hospital tours
Pediatrics and well women care
“Mobile MAMA”
Family Planning
MAMA’S Visits (Home Visits)
MAMA’s Neighborhood Team and Services
Who is Eligible?
Enrolled as a prenatal patient with Los Angeles County Department of Health Services (LAC-DHS).
Patients receive services through their pregnancy period, and up to 10 weeks postpartum.
When the timeframe for medical services with MAMA’S ends, we connect patients to a DHS women’s health provider and pediatrician to continue medical care.
Patients’ Age Groups
O V E R H A L F P A T I E N T S E N R O L L E D ( 2 9 . 2 % + 2 6 % ) W E R E B E T W E E N T H E A G E S O F 2 0 T H R O U G H 2 9 Y E A R S O L D
Patients’ Race
M O S T P A T I E N T S D I D N O T D I S C L O S E T H E I R R A C E
A B O U T O N E - F I F T H O F T H E P A T I E N T S ( 2 1 % ) I D E N T I F I E D A S W H I T E
E X A C T L Y A F I F T H ( 2 0 % ) I D E N T I F I E D A S B L A C K
Patients’ Ethnicity
C L O S E T O T W O T H I R D S ( 6 3 % ) D E S C R I B E D T H E I R E T H N I C I T Y A S H I S P A N I C / L A T I N O
Patients’ Gestational Age at Intake
A B O U T T W O T H I R D S ( 6 5 % ) O F P A T I E N T S E N R O L L E D W E R E I N T A K E D U R I N G T H E I R F I R S T T R I M E S T E R
Clinical Risk Factors
Having an unintended pregnancy (57%), having their first pregnancy (31%), and maternal age greater than 35 yrs. (18%) are the highest risk factors
Referrals to Assessed Service Needs
Progres To Date
Upgrading service sites for improved patient experience
Comprehensive intake assessment
Electronic health record
Individualized Care Plans
Warm in-house hand-offs
Continuity of coordinated care
Breastfeeding support Referral directory Mobile MAMA Prenatal Classes revamped for education and resiliency skills Baby Boutique MAMA’S Visits – Whole Person Care
Baby Boutique
Program Overview
Baby Boutique is a program developed by the Women’s Health Programs & Innovation with Los Angeles County Department of Health Services to help improve pregnancy and birth outcome across Los Angeles County.
Designed to help families obtain items needed for growing families to give children healthier start in life.
New and lightly used baby items are donated from outside agencies for the purpose of redistribution to patients. (Baby 2 Baby & Good + Foundation).
Items are redistributed to patients at various times throughout their pregnancy period. (Intake through postpartum).
Participants receive services through: Clinic/Hospitals, MAMA’S Visits, and Fast Track/Prenatal Classes.
Our Neighborhood
Hospitals and Clinics
Harbor-UCLA Medical Center
21840 S. Normandie Ave.
Torrance, CA 90502
LAC+USC Medical Center
1100 N. State St.
Los Angeles, CA 90033
Olive View-UCLA Medical Center
14445 Olive View Dr.
Sylmar, CA 91342
Bellflower Health Center
10005 E. Flower St.
Bellflower, CA 90706
El Monte Comprehensive Health Center
10953 Ramona Blvd.
El Monte, CA 91731
Martin Luther King Outpatient
1670 E. 120th St.
Los Angeles, CA 90059
Hubert Humphrey CHC
5850 S. Main St.
Los Angeles, CA 90003
Wilmington Health Center
1325 Broad Ave.
Wilmington, CA 90744
Long Beach Comprehensive Health Center
1333 Chestnut Ave.
Long Beach, CA90813
MAMA’s Neighborhood Locations
Psychosocial Risk Factors
M O R E T H A N H A L F ( 5 6 % ) A R E U N D E R - O R U N E M P L O Y E D A N D A R E I N N E E D O FS A F E T Y N E T T Y P E S E R V I C E S ( I . E . , I M M I G R A T I O N , E T C . 5 4 % )
A T L E A S T A T H I R D O F T H E P A T I E N T S H A V E N E E D S I N A R E A S O F E M P L O Y M E N T , E D U C A T I O N , A N D A R E U N M A R R I E D W I T H O R W I T H O U T A P A R T N E R
A T L E A S T A Q U A R T E R H A V E N E E D S I N A R E A S R E L A T E D T O H O U S I N G , T R A N S P O R T A T I O N A N D V I O L E N C E I S S U E S
A L M O S T A F I F T H O F T H E M H A V E E M E R G E N C Y F O O D ( 1 9 % ) A N D A L A N G U A G E B A R R I E R I S S U E ( 1 8 % )
Pregnancy Outcomes
M O S T ( 8 5 % ) O F P A T I E N T S ’ B I R T H S A R E A T T E R M
O N L Y 5 % P R E T E R M A N D V E R Y P R E T E R M
Pregnancy Outcomes
T H E M A J O R I T Y ( 8 6 % ) O F N E W B O R N ’ S W E I G H T I S W I T H I N T H E N O R M A L R A N G E
Referral Process
To refer a patient - Please visit our secure website using the following link: tinyurl.com/mamas4u
For program questions, (e.g. partnership, outreach, education, more information, etc.) e-mail us at [email protected]
For more information, call 844-37-MAMAS.
Whole Person Care – Los Angeles
Whole Person Care – Los Angeles (WPC-LA) delivers seamless, coordinated services to LA County’s most vulnerable Medi-Cal beneficiaries.
High risk
High hospital and emergency department utilization
WPC-LA brings together health and social service agencies to build integrated systems that help provide resources and support.
Homelessness
Justice involvement
Serious mental illness
Substance use disorders
Complex health conditions
Barriers to health pregnancy
The Big Picture
http://dhs.lacounty.gov/wps/portal/dhs/wpc
MAMA’S Visits
Provides support to pregnant and patenting mothers.
Includes mothers who are currently incarcerated, recently released.
Century Regional Detention Center (CRDF)
Office of Diversion & Reentry (ODR)
Extension of MAMA’S Neighborhood.
Mobile Care Team (MCT) provides coordinated and compassionate home-or community based care management services.
Care management is personalized to support low income pregnant and patenting mothers with complex, stressful life issues.
Up to 18 months of quality medical care. (Beings at time of enrollment)
Provides visitation services and support until child is 1 year of age. (Can extend services based on needs).
Focus on preterm birth reduction.
Team Services
Care Coordinators
Maternity mental health providers
Clinical/Psychiatric Social workers
Health Educators
Doctors
Clinic/Public Health Nurses
Community based organizations and agencies
Home or community-based care and support visits (MCTs)
Prenatal care linkage with doctor at MAMA’S Clinic. Birth planning at a MAMA’S Hospital
Family planning education and support
Linked connection to advanced health services: psychiatry, substance use support, violence counseling, high-risk doctors
MAMA’S Visits Team and Services
Services
Group Educational Classes
Pregnancy
Stress reduction
Breastfeeding
Parenting and baby bonding/development
Family planning education
Community Referrals
WIC, housing, jobs, training
School enrollment, childcare
Legal support, transportation
MAMA’S Visits Services Continued
Educational guidance
Healthy pregnancies
Recovery after birth
Baby attachment and development
Mother’s meet-up socials to celebrate motherhood and build a family
Family planning education
Partners for a Healthy Baby
Florida State University – Center for Prevention & Early Intervention Policy.
Research and evidence based home visiting curricula series.
Book series includes:
Before Baby Arrives
Baby’s 1st Year
Baby’s 2nd Year
Toddler’s 3rd Year
Use curriculum to fidelity across all Service Planning Areas (1-8).
Who is Eligible?
Pregnant or recently delivered (enrollment up to 3 months postpartum).
Medi-Cal eligible or low-income.
LA County resident.
Experiencing complex stressful life circumstances.
Identified as medically complex through interview process.
Experience the following indicators:
Preterm birth
Preterm birth risk
History of miscarriage
High blood pressure
Drug use
Level 2 or 3 global risk score (Perinatal Service Intake)
African American
Referral Process
To refer a patient - Please visit our secure website using the following link: tinyurl.com/mamas4u
For program questions, (e.g. partnership, outreach, education, more information, etc.) e-mail us at [email protected]
For more information, call 844-37-MAMAS.
Hospitals and Clinics
Harbor-UCLA Medical Center
21840 S. Normandie Ave.
Torrance, CA 90502
LAC+USC Medical Center
1100 N. State St.
Los Angeles, CA 90033
Olive View-UCLA Medical Center
14445 Olive View Dr.
Sylmar, CA 91342
Bellflower Health Center
10005 E. Flower St.
Bellflower, CA 90706
El Monte Comprehensive Health Center
10953 Ramona Blvd.
El Monte, CA 91731
Martin Luther King Outpatient
1670 E. 120th St.
Los Angeles, CA 90059
Hubert Humphrey CHC
5850 S. Main St.
Los Angeles, CA 90003
Wilmington Health Center
1325 Broad Ave.
Wilmington, CA 90744
Long Beach Comprehensive Health Center
1333 Chestnut Ave.
Long Beach, CA90813
Los Angeles County Service Planning Areas (1 – 8)
MAMA’s Neighborhood Locations
Regional Team Member (SPA’S 1&2)
Karla Brito, MPH, CHES®
Health Educator
Olive View – UCLA Medical Center
(747) 210-4407
Antelope Valley Partners for Health with Children’s Bureau and Black Infant Health
Northridge Hospital Medical Center
Providence Holy Cross Medical Center
Valley Presbyterian Medical Center with El Nido Family Centers
All Health Educators share regional services in SPA 5
Regional Team Member (SPA’S 3&4)
Brandi E. Sankey, MPH, MS, MCHES®
Health Educator
LAC-USC Medical Center
(323) 914-8338
California Hospital Medical Center with Maternal Child Health Access
Citrus Valley Medical Center – Queen of the Valley Campus
White Memorial Medical Center
All Health Educators share regional services in SPA 5
Regional Team Member (SPA’S 6&7)
Eunice N. Soriano, MPH
Health Educator
Hubert Humphrey Comprehensive Health Center
Martin Luther King, Jr. Outpatient Center
(323) 914-8334
Martin Luther King Hospital with SHIELDS for Families
St. Francis Medical Center with SHIELDS for Families
All Health Educators share regional services in SPA 5
Regional Team Member (SPA’S 7&8)
Angelica Campos, MPH, MSW
Health Educator
Harbor-UCLA Medical Center
(424) 306-7220
Centinela Hospital with SHIELDS for Families
Long Beach Memorial-Miller Children’s and Women’s Hospital
Providence Little Company of Mary – San Pedro
St. Mary Medical Center with Families in Good Health
Torrance Memorial Medical Center
All Health Educators share regional services in SPA 5
THANK YOU FOR LISTENING
Brandi E. Sankey, MPH, MS, MCHES®Health Educator
(323) [email protected]
If you have questions about partnerships, please contact:
Angelica Campos, MPH, MSWHealth Educator
(424) [email protected]