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ONE KEY QUESTION®
An initiative of the
Oregon Foundation for Reproductive Health
ONE KEY QUESTION® IN PRIMARY CARE
A simple screening question to facilitate a conversation with your patient regarding her pregnancy intention
Designed to help you ID the preventive reproductive health care needs of your patient’s
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FACTS Most American families want two children.
The average woman is fertile for 39 years and spends 3 decades trying to avoid an unintended pregnancy. She spends about 5 years pregnant, postpartum or trying to become pregnant.
Currently, about half (51%) of the 6.6 million pregnancies in the United States each year are unintended
By age 45, more than half of all American women will have experienced an unintended pregnancy
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Guttmacher Institute- Unintended Pregnancy in the United States- Jan 2015
In Oregon, 2011:
43.5% of pregnancies were unintended
55.7% of all deliveries were paid for by
Medicaid
48.7% of women did not take a prenatal or
multivitamin prior to conceiving
PRAMS 2011: Oregon Department of Human Services, Public Health Division, Pregnancy Risk
Assessment Monitoring System
MORE FACTS
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UNINTENDED PREGNANCY IS ASSOCIATED WITH…
Health problems for both mother and infant including:
Preterm birth, low birth weight, increased infant mortality
Delayed prenatal care
Increased depression, anxiety & physical abuse for mother
5
IN REALITY…
Most unintended pregnancies are unwanted or mistimed, and most could be prevented with better access to contraception
Some unintended pregnancies are wanted, and could be better prepared for with access to preconception care
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CONTRACEPTION WORKS
7 Guttmacher Institute: Unintended Pregnancy in the United States. December 2013
35% of
women at risk
of becoming
pregnancy
have nonuse
or inconsistent
use of birth
control
OUR SOLUTION
Ask all women of reproductive-age One Key Question® as a routine part of primary care:
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PREGNANCY INTENTION SCREENING
One Key Question® is a screening tool to help identify women in need of preventive reproductive health care
framed as “Would you like..” to hear your patient’s own goals for her health
followed by evidenced-based care can have a big impact on your patient population health
9
PREVENTIVE REPRODUCTIVE HEALTH
10
Contraception and preconception care
offered in a proactive and routine way!
THE ONE KEY QUESTION® ALGORITHM
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IF YOUR PATIENT ANSWERS ‘YES’
Preconception Care
Screen for conditions that can affect pregnancy
Review medications
Recommend Folic Acid
Talk about the benefits of birth spacing
12
ADDITIONAL PRECONCEPTION ADVICE
Advice to reduce/eliminate alcohol, tobacco, street drugs
Review prescribed and OTC medications, supplements, herbs
Screen for STIs, diabetes, hypertension
Check if immunizations are up to date
Recommend healthy diet, daily exercise, sleep, stress reduction
Advise a dental cleaning/check up
Screen for risk of intimate partner violence
Establish relationship with primary care provider
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IF YOUR PATIENT ANSWERS ‘NO’
Contraceptive Services
Ask if she is currently using a birth control method
Check on her satisfaction with current method
Offer more options, including long-acting reversible contraceptives (IUD, Implant)
Include information on emergency contraception
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CONTRACEPTION BASICS
Many women use short-term or less reliable contraception because it’s what they are used to
The best method for women usually changes with time or with pregnancy/birth
There are great long-acting reversible contraception (LARC) methods that would be ideal for many women
15
Protect against pregnancy for multiple years
Reduction of user-error: no need for woman to do anything for them to work
More effective than other methods with fewer side effects
Women can have them removed anytime they want with rapid return to fertility
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LARC’S
LARC’S
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Intrauterine Devices (IUDs)
Paragard = 12 years
(no hormones)
Mirena = 5 years
Skyla= 3 years
Implantables
Implanon = 3 years
Nexplanon = 3 years
‘UNSURE’ OR ‘OK EITHER WAY’
Follow up
Offer a combination of contraception & preconception care
Discuss relevant issues
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‘UNSURE’ OR ‘OK EITHER WAY’
Many women are unsure or ambivalent, especially if they’ve never been asked! You can start a conversation:
Is now the right time?
Do you have the resources you need for another child (money, time, child care, space)?
How would having another child impact family work plans, education plans, financial status?
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FOLLOW UP QUESTIONS
Use the 1-10 scale to gauge ambivalence or ask “How important is it to you to prevent pregnancy?”
•“Why would you say you aren’t a lower number?”
•“Why do you think your number might not be higher?”
•“I hear you have mixed feelings, but it’s something you’re thinking about. How can I help?”
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FOLLOW UP RESPONSES:
“I would recommend you chose a contraceptive method to protect against pregnancy until you are sure.”
“I want you to know in a year’s time- 85 out of 100 women who have unprotected sex will become pregnant.
“What would you like to do?”
“How can I help you reach your goal?”
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Risky Assumptions by Providers:
“This person should not become pregnant – I won’t offer preconception care”
“This patient is getting reproductive health care somewhere else”
“This patient knows how to use their birth control correctly”
UNDERSTANDING YOUR PATIENTS GOALS WILL HELP YOU Identify THE PREVENTIVE REPRODUCTIVE SERVICES THEY NEED.
22
OVERCOMING BARRIERS
Time intensive to ask:
“There is not enough time in a PC visit to address RH needs”
Our pilot showed:
OKQ is feasible in a PC visit and acceptable to patients to ask- even at ‘non reproductive health visit.
Only about 30% of women asked will need f/u care.
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OVERCOMING BARRIERS
ONE KEY QUESTION® OUTCOMES
@ Community Health Clinics:
30% of women needed follow-up with contraception or preconception care
70% did not require any follow-up services
@ Public Health Clinics:
60% of women were happy with their current method of contraception
23% received new contraception services
12% were given preconception care and advised to start folic acid
WHY PRIMARY CARE?
25
Screening for pregnancy intention and providing follow-up services is essential for primary care to manage chronic conditions before conception
Pregnancy Intention can change for women throughout the year – so ask often, not only at Well-Woman visits
The ACA now requires insurance to cover preventive care for women including all FDA approved birth control, some preconception care & folic acid, prenatal care, and more!
OTHER SCREENINGS IN PRIMARY CARE
Established Indicators of High Quality Care include
Depression screening (PSQ-2 and 9)
Alcohol misuse (SBIRT)
Cervical cancer screenings (Paps)
Breast cancer screenings (exams, mammography)
Blood pressure
Diabetes screening (blood glucose and HgbA1c)
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LIFETIME RISK
27
ACHIEVE THE “TRIPLE AIM”
Improve health outcomes
Improve the experience of care (quality and satisfaction)
Reduce per capita costs
28
PCPCH METRIC
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Patient Centered Primary Care Home (PCPCH) standard
for age and gender appropriate services that meet the
HRSA-recommended preventive services for women:
Contraceptive methods and counseling
Folic Acid use
“Screening methods described by the One Key Question®
Initiative are adequate to meet these services”
CCO METRIC
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“Effective contraception among women at risk
of unintended pregnancy”
Incentivized metric for Coordinated Care Organizations
for 2015!
Oregon is 1st in the nation to adopt a preventive
reproductive health metric!
ONE KEY QUESTION® IS DESIGNED TO…
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Start a conversation about preventive reproductive health in primary care
Prevent pregnancies that are unwanted or mistimed
Increase the proportion of pregnancies that are better prepared for.
OFRH SUPPORT
Implementation Manual Clinic and Staff inventory
Various algorithms for screening
Custom Consultations Clinic Flow, Data Collection
Additional trainings for providers and team
OKQ patient brochures and posters
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CONTACT US
Oregon Foundation for Reproductive Health
Michele Stranger Hunter- Executive Director
Sharon Meieran, MD, JD- Co Medical Director
Julia Epstein, NP- Co- Medical Director
Hannah Rosenau- Senior Policy & Access Coordinator
info@onekeyquestion.org
Follow us on Facebook and Twitter: Oregon RH
www.onekeyquestion.org
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PREGNANCY INTENTION SCREENING USING:
ONE KEY QUESTION
Jennifer Johnstun, RN
– PrimaryHealth CCO
Maggie Sullivan, MPH – Health Care Coalition of
So. Oregon
Belle Shepherd, MPH
- OHA
FORMATION OF THE CONSORTIUM
1990s - Jackson County Perinatal Task Force formed by Jackson County Medical Director
2008 - Josephine County Perinatal Task Force formed by Josephine County Public Health Manager
2012 – Southern Oregon Perinatal Task Force forms, merging efforts of both counties, and relationships with Managed Care Organizations continue through formation of CCOs
ORGANIZATIONS IN THE CONSORTIUM
Public Health – Jackson and Josephine
CCOs – Allcare, Jackson Care Connect, PrimaryHealth
FQHCs – Siskiyou Community Health Center, La Clinica, Rogue Community Health
Other partners: Women’s Health Center, Siskiyou Pediatrics, Asante Health Systems, DCOs and Dentists, Family Nurturing Center, Drug and Alcohol clinics, Head Start and Early Head Start
MISSION STATEMENT
To improve the health and well-being of pregnant women, infants, and young children by empowering women and families to make healthier choices for
themselves and their babies, before, during and after pregnancy.
(Adopted January 2013)
FUNDING RECEIVED FROM OHA, COMMUNITY PREVENTION GRANT
Fiscal Agent & Project Direction-Funded 10/2013:
Jackson County Public Health
Project Management:
Health Care Coalition of Southern Oregon
A 501(c)-3 non-profit organization made up of public health agencies & community health centers in Jackson, Josephine & Douglas Counties
HEALTH OUTCOME MEASURES TO BE TRACKED
The steering committee for the Community Prevention Grant determined the following outcome measures:
Early Entry into Pre-natal Care
Teen Pregnancy Rate
Teen Birth Rate
Unintended Pregnancy Rate
Contraceptive Use Rate
ONE KEY QUESTION (OKQ) IMPLEMENTATION
Steering committee formed to:
Identify champion agencies to start screening
Plan for training and education efforts
Review materials to be used
Address implementation problems
ROUTINELY SCREEN WOMEN FOR THEIR PREGNANCY INTENTIONS (ALIGNED WITH OHA STRATEGY #1)
Paper form used by WIC, MIECHV Programs:
WORK UNDERWAY TO EMBED OKQ IN OCHIN/EPIC & OTHER EMR SYSTEMS
Medford FQHC, La Clinica, initiated request to build OKQ algorithm into OCHIN/EPIC.
Work teams provided input on work flow outline (Outside-In, Multnomah Co PH, Wallace Medical Concern, OPCA, La Clinica).
CareOregon donated staff time to assist with build. Build in-process
Other clinics looking at how to embed in their EMRs
Efforts to integrate OKQ with EMRs make it easier for providers to implement an OKQ workflow
OHA STRATEGY #2: REMOVE BARRIERS TO CONTRACEPTION
Education for providers and members regarding OHP’s coverage of all methods of birth control (and how/where to obtain this from CCOs).
Request to local CCOs to provide at least 3-month supply of Birth Control Pills
Client education on effectiveness of methods
STRATEGY #3: IMPROVE AVAILABILITY AND INCREASE REFERRALS FOR LARCS – LONG-ACTING REVERSIBLE CONTRACEPTION
Development of Local Family Planning Referral Grid, with info on where to get contraceptives
Education Materials
Contraceptive Update Training for providers and clinics
Title X
(Title 10)
CCARE OHP Private Ins Sliding Scale Walk-in
Welcome
Methods offered
Ashland Clinic
541-482-9741
99 Central Ave
Ashland, OR 97520
Medford Clinic
541-773-3863
19 Myrtle St
Medford, OR 97504
White City Clinic
541-826-5853
8385 Division Rd
White City, OR 97503
Butte Falls Clinic
541-842-7799
722 Laurel Ave
Buttle Falls, OR 97522
Phoenix Health Center
3617 S. Pacific Hwy
Medford, OR 97501
West Main Health Center
1307 W. Main St.
Medford, OR 97501
Women's Health Center
910 S. Central Ave
Medford, OR 97501
Central Point Health Center
4940 Hamrick Rd.
Central Point, OR 97502
1701 NW Hawthorne Ave
Grants Pass, OR 97526
25647 Redwood Hwy
Cave Junction, OR 97523
Title X (Title 10)
1. Live in Oregon
2. Have income up to:
IUD
Pills
Implants
Ring
Shot
Patch
Condoms
Emergency Contraception
●
● ● ● ● ● ●
● ● ● ● ●
● ● ● ●
●
● ● ● ●
IUD
Pills
Implants
Ring
Shot
Patch
Condoms
Emergency Contraception
For private insurance, call you insurance company, and ask to speak with a representative.
Primary Care - You may have a primary care provider that offers Family Planning Services
● ● ● ●
● ● ● ●
●
Oregon Contraceptive Care (CCARE): CCARE offers free contraceptives, contraceptive counseling and annual exams to women and men who meet financial
guidelines and eligibility requirements listed below:
Family Planning Referral List for Jackson and Josephine Counties
Ring
Pills
Shot
Patch
Condoms
Emergency Contraception
IUD
Pills
Ring
Shot
Patch
Condoms
Emergency Contraception
IUD
Pills
Implants
Ring
Shot
Patch
Condoms
Emergency Contraception
IUD
Pills
Implants
Ring
Shot
Patch
Condoms
Emergency Contraception
Clinic
Jackson County Public Health 541-774-8209
Community Health CenterIUD
Pills
Implants
Ring
Shot
Patch
Condoms
Emergency Contraception
1005 E. Main St
Medford, OR
**Moving in December 2014**
140 S. Holly St.
Medford, OR 97501
715 NW Dimmick St
Grants Pass, OR
● ● ● ● ●
La Clinica 541-618-1300
Planned Parenthood 541-344-9411
Josephine County Public Health 541-474-5325
Siskiyou Community Health Center
541-472-4777
Women's Health Center of Southern Oregon
541-479-8363
Ashland Medford
1532 Siskiyou Blvd. 125 S. Central Ave
Ashland, OR 97520 Medford, OR 97501
Grants Pass
160 Franklin Blvd
Grants Pass, OR 97526
Title X (called "Title Ten") is a Federal Grant Program providing confidential family planning and reproductive health services to low-income, uninsured, and undocumented individuals at
reduced or no cost. Title X Clinics cannot refuse services based on ability to pay, and offer a sliding scale fee based on income. Individuals at or below the federal poverty level pay
nothing.
4. Have a Social Security number (SSN)
If you have health insurance, they MUST cover ALL birth control methods at NO COST to you. If you are uninsured, you may
still qualify for free or low cost birth control under Title X (10) or Ccare, please see guidelines below.
3. Present photo ID
AllCare CCO - 541-471-4106 Jackson Care Connect CCO - 1-855-722-8208 Primary Health of Josephine County CCO - 541-471-4208
1075 SW Grandview Ave Suite 200
Grants Pass, OR 97527
For Oregon Health Plan , contact your Care Coordinated Organization (CCO).
1 $561 $2,4322 $756 $3,2783 $951 $4,123
For each additional person add: $195 $846
Version 3 , update 8/2014
STRATEGY #4: CREATE QUALITY IMPROVEMENT PROCESSES FOR PRECONCEPTION & CONTRACEPTIVE CARE
Initial OKQ Data from WIC was compiled. WIC staff receives data back for QI regularly.
What percent of women not currently on BC were referred for contraception?
What percent of women are taking daily multi-vitamins?
What percent of women receive info on preconception health & primary care?
WIC DATA ( JACKSON COUNTY NOVEMBER 2014 )
WIC DATA “YES”
WIC DATA “NO”
WIC DATA “NO, AND USING BIRTH CONTROL”
STRATEGY #5: BUILD PROVIDER AWARENESS AND CAPACITY FOR EFFECTIVE CONTRACEPTIVE USE
Reproductive Health Update Training - November 13, 2014 –Presented by CARDEA & Dr Deborah Oyer
Plenary Contraceptive Update Attended by 80
Clinical Case Management for Contraceptive Care – Attended by 30 providers
Contraceptive Counseling Session- attended by 30 health workers
IUD Insertion Training – attended by 30 providers
Nexplanon Insertion Training – attended by 25 providers
STRATEGY #6: ENHANCE PARTNERSHIPS WITH LOCAL FAMILY PLANNING CLINICS
Outreach to family Planning clinics – distribution of patient education materials and multi-vitamins
Roll-out of One Key Question at County Health Dept Family Planning Clinics
Family Planning Referral Grid
How do we build motivation to address this? (One Key Question is One More Thing)
How does this fit into each PCPCH’s vision for how they wish to provide care?
How can CCO and clinic priorities align(Ex: Shared Decision Making?)
What did we learn from SBIRT implementation that can help us with rolling out this initiative?
How can we work together as a community of providers to accomplish this?
CONCEPTS FOR CCOS TO CONSIDER
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