Lisa Schlar, MDDirector of Womens HealthUPMC Shadyside Family Medicine Residency Pittsburgh, PA

Jessica Brubach, ICC Project CoordinatorFMEC IMPLICIT Network

ObjectivesIntroduce IMPLICIT Network Examine rationale, evidence and benefits of interconception care (ICC) strategies Present ICC ModelReport initial outcomesProvide ICC toolsDiscuss challenges

IMPLICIT NETWORKInitiated Fall 2003Collaboration of family medicine residency programsEvidence-based prenatal interventions to reduce LBW/prematurityGoal to restructure curriculum and practice to improve quality of care and patient outcomesInterventions to Minimize Preterm and Low Birth Weight Infants using Continuous Improvement Techniques

Family Medicine IMPLICIT Networkin collaboration with March of Dimes and Family Medicine Education Consortium

Prenatal Care: The DilemmaBy the time a woman enters prenatal care, it is often too late to significantly affect the outcome of the pregnancy.

Neural tube closes 28 days after conception

Placental development begins 7 days after conception

INTERCONCEPTION CARE: RationaleNational Priority CDC MODEarly and adequate prenatal care doesnt reduce LBW/prematurity Unintended pregnancies :Increased detrimental prenatal behaviorsIncreased risk of preterm and low birth weight (LBW) babiesNegative health & social outcomes for mother and childShort interpregnancy intervals (

Barriers to Interconception CareNo access to careLack of insuranceNo established modelNo clinician time to addressFocus is on the infantHeneghan et al, 2007/ La Rocco et al, 2003; Kahn et al., 1999, Muchowski, et al, 2004

MATERNAL SCREENING During WCV - EvidenceMothers take child to WCV without caring for self Majority accept inquiry about own health at WCV Maternal tobacco screening at WCV showed high rates of use impact on childMaternal depression screening & referral at WCV + impact on child

Gjerdingen et al, 2009/Heneghan et al, 2007/Roske et al, 2009

Family Physicians are Best Equipped to Provide Interconception Care

I believe that my health affects the health of my children and children from future pregnancies.

82.0%18.0%TrueI am willing to take advice about my health that affect my children from my childs doctor.TrueFalse94.5%5.5%FalseMothers Health During WCV Baseline Survey 2011 (N=672)

Chart1

5.594.5

No

Yes

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No5.5

Yes94.5

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1882

No

Yes

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No18

Yes82

IMPLICIT ICC Baseline SurveyMaternal Demographics (N=672)Majorityare seen in our offices (75.7%)with Medicaid insurance (73.93%)African Americans or Latino (66.3%)Finished: some college, no degree (30.77%) high school (30.77%)Young moms: 25.00% were < 22 y/o at childs birth

IMPLICIT ICC MODELICC focuses on 4 behavioral risks SmokingDepressionFamily PlanningMultivitamin w/Folic Acid Use

IMPLICIT ICC Strategy: Smoking Cessation20% of smokers quit during pregnancy 70% who quit will relapse within 6 mos PP

Assess maternal smoking status Recommend cessation BEFORE (the next) pregnancy using 5 As:AskAdvise to quitAssess willingness to quit within 30 daysAssist with ways to quitArrange follow-upLumley J, et al, 2007/ Muchowski et al. 2004/Windsor RA, et al., 1993

Sxs occur in 20-40% of women during or PPDepression has a peripartum recurrence of 40%

Screen women for depression with PHQ-2 PHQ-9 if + PHQ-2If + Depression:Assess for safety and severity of symptomsRefer immediately if any suicidality or homicidality is presentArrange for follow-up and servicesBennett IM, et al, 2010/Chung EK, et al, 2004/ Murray L, et al, 2003/Weissman MM, et al, 2006 IMPLICIT ICC Strategy Depression Screening

Unintended pregnancies and short IPI assoc w/ risk of LBW/PrematurityAntenatal counseling doesnt improve use

Assess women for contraception useEducate about benefits of longer IPIOffer contraception or arrange appointment or referralConde-Agudelo, et al, 2006/Smith, et al, 2002IMPLICIT ICC Strategy Family Planning

Routine folic acid supplementation reduces the rate of NTD by 66%, MVI even moreMVI w/folic acid assoc with 50% - 70% less PTBOnly 24% of US women consume; Only 1 in 5 know

Assess MVI w/folic acid use Rx MVI w/ folic acid to all women

Czeizel, AE, et al, 2004/De-Regil, LM , 2010/Muchowski et al, 2004/Tinker SC, et al, 2003IMPLICIT ICC Strategy Multivitamin w/Folic Acid Use

IMPLICIT ICC StrategyUtilize contact with mothers at WCVAssess current risks at each WCV 0-24 moReinforce desired behaviorsConnect with primary providers or community resources to address risksCollect and analyze data and develop strategies to improve care delivery

Initial Network Outcomes (since 2012)Live at 8 Network sitesTrained more than 400 providersScreened for ICC more than 5,500 timesFollow more than 2,800 unique mothersGoing live at more 8 sites by Summer 2014

Initial Network Outcomes

Behavioral Risk Factor (N=715)Positive (+) Screen (% of visits)Counseling/Treatment (% of visits)Smoking 30.25%94.90%Depression 11.90%100.00%Lack of Contraception 20.0% 79.90%Not on Multivitamin 53.50%59.60%

Key ICC ProcessesAssessments must be systematic & efficientAssign members of your teamEstablish plans at how to address positive screens, including response to suicidalityScreen at every visit to increase ratesMake patient/provider education part of planIf part of CQI, it must be measured, make your EMR do the workGive ongoing feedback to team

ICC Tools Create Office Flows

ICC Tools Create Office Flows

ICC Tools Calculate Monthly Screening Rates

ICC Tools Patient Education

ICC Tools Utilize your EMR

Overall ICC Implementation Rate: 84.6%ICC Implementation Rate Goal: 75%ICC Tools Give Monthly Provider Feedback

Well Child Visit ReportMonthProviderValencia, RiaAug-12Sep-12Oct-12Nov-12Total

Total Number of WCV119213Total Number of WCV with ICC117211

ICC Implementation ChallengesLack of provider engagement Generate awareness, interest, competenceFamily docs in unique position to care for mother and infantPeds can do with education and referrals Performing ICC without an EMRUse paper tool, manual chart review

Conclusion

IMPLICIT ICC is a brief, efficient, innovative strategy to improve maternal health prior to the next pregnancyScreening and treating mothers with tobacco use, depression, without contraception or multivitamins during WCV can improve birth outcomesData driven care is critical to effective CQI initiatives Need a systematic approach to screening, data collection, analysis and feedback Essential to have dedicated multidisciplinary teamNeed funds for admin personnelOngoing monitoring of identified maternal health risks to reinforce desired behaviors and offer interventions will improve overall maternal health and ultimately reduce the risk of LBW/premature infants

Preventing Prematurity One Woman at a Time10 years later10,000 women in the database

Please visit fmec.net or Contact Jessica Brubach, ICC Project Coordinator brubachjl2@upmc.eduWant To Learn More About The IMPLICIT Network Interconception Care (ICC) Project?

REFERENCEBennett IM, Marcus S, Palmer S, Coyne JC. Pregnancy related discontinuation of anti-depressant use and depression care visits among Medicaid recipients. Psychiatric Services. April 2010;61(4)386-91. PMID 20360278. Chung EK, McCollum KF, Elo IT, Lee HJ, Culhane JF. Maternal depressive symptoms and infant health practices among low-income women. Pediatrics. 2004;113:e523-9.Conde-Agudelo,A., et al. Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis. JAMA, April 2006; 295:1809-23.Czeizel, AE. The primary prevention of birth defects: Multivitamins or folic acid? Int J Med Sci. 2004;1(1):50-61.De-Regil, LM, Fernndez-Gaxiola, AC, Dowswell, T, & Pea-Rosas, JP. Effects and safety of preiconceptional folate supplementation for preventing birth defects. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD007950Gjerdingen D, et al. Postpartum Depression Screening at Well-Child Visits: Validity of a 2-Question Screen and the PHQ-9. Ann Fam Med, 2009.Heneghan A., et al. Paediatricians Attitudes about Discussing Maternal Depression During a Paediatric Primary Care Visit. Child: Care, Health & Development 2007.Kahn R. & Wide P. The scope of unmet maternal health needs in pediatric settings. Pediatrics, 1999.LaRocco A., et al. Depression screening attitudes and practices among obstetrician-gynecologists. Obstet Gynecol, 2003. Lu M., et al. Preconception care between pregnancies: the content of internal care. Matern Child Health J, 2006.

Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. The Cochrane Database for Systematic Reviews. Volume (3), 2004. Accessed online on 3/28/07. Muchowski K., et al. An ounce of prevention: The evidence supporting periconception health care. The Journal of Family Practice, 2004.Murray L, Cooper PJ, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child relationship and child outcome. Br J Psychiatry. 2003;182:420-7. Roske K., et al. Smoking Cessation Counselling for Pregnant &Postpartum Women among Midwives, Gynaecologists and Paediatricians in Germany. Int J Environ Res Public Health, 2009.Smith, KB, et al. Is Postpartum Contraception Advice Given Antenatally of Value in Contraception, 2002Tinker SC, Cogswell ME, Devine O, Berry RJ: Folic acid intake among U.S. women aged 15-44 years, National Health and Nutrition Examination Survey, 2003-2006.Weissman MM, Pilowsky DJ, Wickramaratne PJ, Warner V, Pilowsky D, Verdeli H. Remissions in maternal depression and child psychopathology: a STAR*D-child report. JAMA. 2006;295:1389-98. Windsor RA, Lowe JB, Perkins LL, et al. Health education for pregnant smokers: its behavioral impact and cost benefit. Am J Public Health 1993;83: 201-206. REFERENCE

OR WHATEVER YOU WANT TO FOCUS ON.*Network of FM residency programs that uses the CQI process to improve care of women and their infants before, during and after pregnancy

13 participating residencies in 5 states currently active in ICC

*CDC Select Panel Encourage each woman and couple to have a reproductive life plan.Deliver preconception interventions focusing on those interventions with high population impact and sufficient evidence of effectiveness.Use the interconception period to provide intensive interventions to women who have had a prior adverse pregnancy outcome (e.g., infant death, LBW, preterm).

Unintended pregnanciesIncreased detrimental prenatal behaviorsIncreased risk of preterm and low birth weight deliveryNegative health & social outcomes for mother and childShort interpregnancy intervals (1 barriersWomen during pediatric visits: 2/3 had health problems (smoking, alcohol abuse, depression, violence, risk for unintended pregnancies, serious illness)Loss of Insurance coverage:MEDICAID target: after becoming pregnant 60 days post delivery no coverage before or between pregnanciesProvider concerns: During routine gyne/preventative visits: preconceptional health promotion commonly missed ()Only of reproductive aged women receive counseling about pregnancy planning ()Provider concerns:OB Gyne not comfortable addressing identified risks such as depression (La Rocco et al, 2003)Pediatricians not comfortable / adequately trained to address maternal risks such as depression or tobacco use (Heneghan et al, 2007)Maternal focus on the infantPATIENT barriersLimited access to caremoms rarely come for separate appt (Kahn et al., 1999)maternal focus on infant to the exclusion of their own needs Loss of Insurance coverage no coverage before or between pregnanciesPROVIDER barriershealth promotion NOT commonly addressed (Bernstein et al, 2000 / March of Dimes, 2004 / Hillemeier et al, 2008) OB/Peds not comfortable addressing maternal risks (La Rocco et al, 2003 / Heneghan et al, 2007)OTHERS: Lack of established model for delivery of ICC (IMPLICIT, 2010)

*Mothers visit peds, even if they dont establish primary care for themselves

*What Did Our Moms Say about ICC Model?*I THINK WE SHOULD BIRELF SAY THAT THERE IS MEDICAL LITERATURE TO SUPPORT THESE 4 RISKS AND YOU CAN FIND THE RESEARCH IN THE EVIDENCE SUPPORT IN PACKET

ABSTRACT READ:ICC is a brief, efficient model that works to address tobacco use, maternal depression, multivitamin use, and compliance with contraception to increase inter-pregnancy interval by questioning potential mothers when they come in with their children. For each area, clinicians assess current risks; reinforce desired behaviors and offer interventions to promote desired behavior; and connect mothers with the necessary providers or community resources. Mothers are repeatedly assessed as the families return for future visits, ensuring that positive messages can be reinforced by the provider.

*Smoking highest proportion of preventable problems related to pregnancy and the neonatal periodIncreases risks of: placenta previa, placental abruption, ectopic pregnancy, preterm PROM, stillbirth, IUGR, SIDS

25% reproductive aged-women in US are smokers 90% continue up to pregnancy;

*Untreated postpartum depression is associated with poor parenting practices and infant behavioral development2, 3.Risk of psychopathology in infants is reduced by effective treatment of depression in mothers4.

*Lowest risk for LBW = 18-23 mosStandard antenatal counseling alone does not improve postpartum contraceptive use

*Only 20% knew: folic acid could prevent certain defectsOnly 7% knew: have to take folic acid prior to conception

*THigher implementation rates:Ensures maternal health risks are identified and addressed over timeCurrently collecting health risk dataWill monitor changes on health risks over timeEnables us to get more accurate health dataIdentification of strengths, weaknesses, needs, etc. of ICC projectEvaluation of the ICC modelHIS IS NETWORK AND OUR REPORT ONLY INCLUDED PA PROGRAMS.I ADDED MAHEC NUMBERS TO TOTAL SCREENINGS AND UNIQUE MOMS. THERE MAY EVEN BE MORE THAN UPMC, MAHEC, AND LGH BUT I AM NOR SURE AT THE CURRENT MOMENT IT WOULD BE HARD TO LOOK AT BEHAVOR OUTCOMES BECAUSE I DO NOT HAVE MAHEC #S

ABSTRACT READ:Addressing behavioral risks that a woman can control during the pre/interconception period can improve maternal health and birth outcomes for subsequent pregnancies. Our ICC model offers an innovative way to address these risks effectively with women in the context of their families.

*Talk about resources

ALSO REFER THEM TO DATA COLLECTION FORM TO SEE WHAT WE ASK

BRIEFLY MENTION SOME SITES USE PAPER BASED FORMS BECAUSE IT ALL GOES IN REDCAP ANYWAY*ONE OF MOST IMPORTANT THING IS WHAT WE ASK.

ALSO REFER THEM TO DATA COLLECTION FORM TO SEE WHAT WE ASK

BRIEFLY MENTION SOME SITES USE PAPER BASED FORMS BECAUSE IT ALL GOES IN REDCAP ANYWAY*Provider Engagement RN/MA/MD if not motivated or interested or have knowledge wont be successful

*

Addressing behavioral risks that a woman can control during the interconception period can improve maternal health and birth outcomes for subsequent pregnancies. Our ICC model offers an innovative way to address these risks effectively with women in the context of their families.

Interconception Care (ICC) is an emerging model designed to identify and potentially modify behavioral risks to improve future pregnancy outcomes. Because mothers accompany children to the doctor, the childs well child visit (WCV) offers a consistent, common point of contact between physicians and women between pregnancies. ICC is a brief, efficient, innovative model that works to address tobacco use, maternal depression, multivitamin use, and compliance with contraception by questioning potential mothers when they come in with their children. Addressing behavioral risks that a woman can control during the interconception period can improve maternal health and birth outcomes for subsequent pregnancies.For each of these areas, clinicians: (1) assess current maternal risks; (2) reinforce desired behaviors and offer interventions to promote desired behavior; and (3) connect the mother with primary providers or community resources to address risks.

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