family solutions of the low country · 2015 sc boi symposium november 10, 2015 virginia berry...

Family Solutions of the

Low CountryMulti-Disciplinary/Multi-Institutional Groups

Building Impact and Strengthening

Perinatal Systems

2015 SC BOI Symposium

November 10, 2015

Virginia Berry White, LMSW

Director/Administrator

Learning Objectives

• Team Approach to Improving Care

• Benefits of a Multi-Disciplinary Team

• Building and Changing Systems

• Care Coordination and Collaboration

• Strength of Team/Filling in Gaps

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Program Background

• Family Solutions of the Low Country is an expansion of Low Country Healthy Start.

• Mission: To promote healthy lifestyles through education and social development

• Vision: Families will achieve optimal health to impact lifelong changes and improve quality of life

• Focus: Rural, underserved families and communities

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Program Background

• Service area: Allendale, Bamberg, Barnwell, Hampton and Orangeburg Counties

• We are a program of the South Carolina Office of Rural Health.

• Fully operated since October 1997 – in four of the five counties

• Programs include Nurse-Family Partnership Program; Opportunity Knocks (Male); Tomorrow’s Scholars’ Leadership Program.

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Program Background

• Comprehensive, coordinated health & social services

• Ensure access to community-based, culturally sensitive and family-centered services

• Home visiting program

• Referral and ongoing health care coordination for prenatal, postpartum women, men and well-child care

• Case management and linkage to social services;

• Smoking cessation counseling, drug & alcohol services

• Nutritional counseling and breastfeeding support

Groups Necessary to Significantly

Reduce or Eliminate Perinatal

Disparities

• Clients

• Women of Child Bearing Age in the Service Area (WCBA)

• Family members

• Partners and significant others of clients and WCBA

• Community citizens

• Payers and insurers

• Perinatal Providers

• Policy makers – local, state, federal

• Community and civic leaders

• Faith leaders

• Social service providers

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FSLC Approach – What? Why?

• In 2002, we had the idea of forming multi-disciplinary teams (MDT) designed to forge a closer connection between FSLC and obstetric perinatal providers.

• Teams were composed of FSLC staff and major prenatal and post-partum care providers caring for women including, • Certified Nurse Midwives, Nurse Practitioners,

• Physicians,

• Medical Office Assistant.9

Meeting Format and Process

• We developed the structure and format.

• Over time it has changed little because it works.

• Participant practices were selected from providers who provide care to the majority of AA women covered by Medicaid

• Practices include Federally Qualified Health Centers, Rural Health Clinic, traditional or hospital owned practices

• Meetings are practice focused, i.e. which clients are in that practice.

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Meeting Format and Process

• We invited participation based on who provided the most care to our target population – African American women at risk

• Practice participants are provided a token payment to help defray loss of practice income during meetings and preparation.

• Began the meetings in 2002 with three practices.

• We have expanded significantly in the past 13 years.

• The service area only has one birthing hospital.

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Number of Clients Reviewed

According to program records:

• In program year 2013, 566 clients were staffed or

reviewed with providers during MDT meetings.

• In program year 2014, 542 clients were staffed or

reviewed with providers during MDT meetings.

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Conduct Monthly Meetings• Monthly meetings

• Agenda driven

• Confidential communication

• HIPPA considered

• Discuss specific patients

• 1.5 hours per meeting

• LMSW and Nurses prepare the agenda in advance

• Communicate with provider which clients are to be discussed

• LMSW & Nurses prepares post-meeting notes for internal use

• LMSW, Nurses and Client Navigators participate

• All workers can suggest a client to discuss in MDT meetings13

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What works?

Why do we think so?

Who benefits?

What are the benefits?

Care Coordination/Collaboration

and Benefits

• Patient leaving hospital with a method

• Presumptive eligibility contributes to early enrollment

• Monitoring & ensuring medical regimen is followed

• Recommendation from Provider for follow up

• Medical Needs of Clients are discussed

• Psychosocial Needs of Client is addressed

• Quarterly Perinatal Action Network (PAN)15

From our Perinatal Partner Practice

Point of View ...

Benefits from MDT meetings are numerous.

• We learn from the FSLC staff about the client’s home situation and home stress.

• Pregnancy is a very vulnerable time for clients.

• The advocacy and close connections of FSLC staff with clients help the clients cope with the pregnancy

• FSLC helps clients plan for the present and future by discussing and planning,

• how to take care of themselves during pregnancy.

• attendance for all prenatal visits. 16


Point of View ...

• FSLC helps clients plan for the present and future by discussing and planning,

• how to prepare for and care for the newborn

• how to make a solid family planning plan

• go back to school, if needed

• find work

• find a safe place to live

• find appropriate child care. 17


Point of View ...

• First, yes it works.

• Why?

• Because we are focused on specific clients and address specific concerns.

• Because FSLC staff are well prepared.

• Before the MDT meeting, FSLC staff review the medical and program records of clients to be discussed.

• FSLC adds clients to the discussion list when we have concerns.

• Providers add clients to the discussion list too.18


Point of View ...

• The structure and specificity aid us in providing specific feedback to FSLC staff.

• The specific feedback can then be applied in other similar cares.

• The specific client centered discussions aid us in learning and teaching, as well as joint care planning.

• The meetings are systematic, planned, efficient and structured which help with using our time effectively.

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Point of View ...

• Clients who are joint clients of our practice and FSLC are

better informed.

• FSLC clients better understand what is happening to their

bodies and what to expect

• They are more focused on what they need to do to have a

healthy baby.

• If the client is really struggling with life, FSLC helps the

client find more resources.

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Point of View ...

• FSLC helps bridge the huge gap between what clients need and have.

• The mental health system in our service area is broken. It is overwhelming and when we all work together it is better.

• Many of our patients have no support. Many struggle with,

• living alone,

• history of drug abuse,

• not having custody of other children,

• Living in crushing poverty. 21

What works from the Perinatal

Partner Practice Point of View?

• FSLC helps our practice understand the complexity of the lives of joint clients especially the stress of living in poverty.

• Understanding helps us help our clients cope with the many challenges they face.

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What works from the FSLC Point

of View?

• We learn more specifics about the clinical side of prenatal, post-partum and interconceptional care.

• We advocate for our clients directly with their chosen provider.

• We provide our partner insight into home situations and other client stress points.

• We strategize with providers on what to do to help clients meet health and family objectives.

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What works from the FSLC Point

of View?

Working directly with the providers helps us reinforce what their provider is advising them.

We increase our ability to advise clients adequately and accurately.

We give our clients feedback and encouragement with more confidence.

We can directly ask questions the client may have been uncomfortable with asking or forgot to ask.

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How do we work with other

providers and partners?

• Perinatal Action Network

• Community Action Network

• Both groups meet quarterly

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Perinatal Action Network

• Preceded by the Perinatal Provider Advisory Group,

which has met quarterly for the past decade.

• Group is made up of obstetricians, pediatrician,

nurse midwives, nurse practitioners, hospital obstetric

unit nurses, public health nurses, childbirth educators,

regional center nurses, lactation hospital and FSLC

staff, nurse educators and FSLC staff.

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• The PAN (and the PPAG before) identifies and then

works to resolve or improve specific perinatal system

issues, such as:

• How to assure women leave the hospital with an effective

birth control method;

• How to assure women get back to their provider for a

postpartum visit and selection of an effective, long acting

reversible contraceptive method;

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• How to assure women get early prenatal care regardless of

insurance status;

• How to assure women and infants have a primary care medical

home for at least two postpartum and infant years;

• How to assure system issues, payment issues, provider availability

issues are recognized quickly and a plan is made to resolve issues.

• We review FSLC program data to tract the number of

women who leave the hospital with an effective birth

control method & the # and % of women using an

effective method at specific intervals after delivery. 28

Community Action Network

• The CAN is a broader group made of civic leader,

faith leaders, social service leaders, clients, client’s

families, client’s husbands or partners, educators,

mental health providers, law enforcement,

community activists, public health providers, insurers,

hospital personnel, safety providers.

• The CAN meets quarterly, with some committee and

task group work done between meetings.

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• Working on two specific issues to help improve the

lives of FSLC enrolled women and WCBA in the

service area:

• Child care –available, high quality,

accessible, affordable, child care.

• Education – secondary, community college,

college, technical schools, GED.

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• The CAN engages in problem solving. They:

• Raise awareness and funds to directly assist clients who are

in dire or perilous situations.

• Provide scholarships for a few FSLC clients.

• Provide child safety seats if the parents cannot afford one.

• Provide feedback on what is happening in the five counties

and discuss what action needs to be taken by members and

FSLC.

• Work to develop men’s education and support services. 31

FSLC, in Collaboration with Partners, Work

to Impact the Entire Perinatal Continuum

Perinatal Around

Birth

Preconception

Pregnancy

Birth/delivery Infant health

to age 2

Family planning for

2 years

MDT,PAN, Community Action Network

MDT and Perinatal Action Network

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Questions???

Comments??

Observations?

Closing Comments

• FSLC values the partnerships that are essential to

improving perinatal outcomes and eliminating disparities.

• FSLC invests time and resources to nurturing our

partnerships because they are essential.

• Without active devotion and nurturing – the partnerships

with obstetric providers(MDT), perinatal system providers

(PAN) and community providers and leaders (CAN) -would

not be as effective as they are.

• Strong partnerships require work and attention. 34

Closing Comments

“In a Real Sense all Life is

Interrelated…Whatever affects one

directly affects all indirectly”

Dr. Martin Luther King, Jr.

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Contact FSLC

For more information contact Family Solutions of

the Low Country at 803 531 8008

or by e-mail to

[email protected]

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family solutions of the low country · 2015 sc boi symposium november 10, 2015 virginia berry...

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