A Model Program for Patient Navigation

Using the Justice System to offer a Health Care Intervention to Improve Birth Outcomes

Susan Holsapple, PhD(Boston University)

Mary Jensen, MSW

Evaluation

Patient Navigation for Court Mandated Women

Purpose

The purpose of this presentation is to describe a unique and innovative program that uses an encounter with the justice system to offer a health care plan for a subset of people going through drug court. With the application of social theory to clinical practice, an intervention in the form of patient navigation is developed to meet the needs of these clients. This presentation will offer a description of the program and evaluation tools that may be used for standardization and subsequent replication of this patient navigation model to improve negative birth outcomes. Constraints on choice may be used to explain the process of health care decision making for the court involved population, and patient navigation within the framework of this model offers a cost-effective means of improving health care outcomes.

Financial Disclosure

We have no relevant financial relationships to disclose.

Objectives

1) To demonstrate the efficacy of patient navigation in order to improve maternal/child health outcomes and parenting skills for the court involved population by presenting a patient navigation project that was successfully piloted in New York State.

2) To demonstrate the efficacy of patient navigation in order to improve maternal/child health outcomes and parenting skills for the court involved population by presenting a patient navigation project that was successfully piloted in New York State.

3) Identify the tools that are needed to replicate the model in other locations.

AbstractFormatQualitative study – court mandated women who are pregnant or parenting a child < 5 years oldFocus –

methods of access to healthcare, barriers, and interaction with the mainstream health care community. Goal – Evaluation of a program in order to create a model for patient navigation through the justice system

MethodsOpen-ended interviews (audio-taped and transcribed). Participant observation

-explore treatment modalities options available to high risk pregnant women and their children

Primary data sources Women (pregnant or parenting), n = 47

Secondary data sourcesInfectious disease specialist, n = 1Navigation Nurse, n = 1Family practice physician, n =1Family Court Social Worker, n = 1Patient Navigation Social Worker, n = 1The observations took place at three locations: a clinic designed to promote treatment and drug adherence, individual

appointments with the women and their OB/GYN provider, and the Community Treatment Court (SCTC)

Abstract• The purpose of the evaluative study was two-fold; one was to evaluate a

grant supported program that used the justice system to offer patient navigation services and the second goal was to provide a qualitative evaluation of the women’s health care experiences as they went through a court mandated drug program. Primary data was obtained from interviews with forty-seven program participants (n=47) from March, 2008 until January, 2010, and participant observation was used to explore treatment modalities and options available to these women. Secondary data was obtained from program staff as well as a review of the survey evaluation process by the staff where data was collected through participant surveys. The findings suggest that poor outcomes for the women and their children are related to socioeconomic and/or behavioral barriers that produce difficulties forging successful relationships with traditional health care providers. When interventions that promote advocacy and empowerment are in place, there seems to be an improvement in outcomes for the mothers and their children.

Background of StudyProblems: 1) Infant Mortality

Rate of 9.5 for city under study10.2% of births were low birth weightPreterm low birth weight was 12.1

2) Infant mortality rates are higher for the group of court involved women – (as well as having 16% greater chance of having a premature birth or negative birth outcome)

3) Infant mortality rates are higher for women who report alcohol abuse, substance abuse, and/or mental illness (Bada, 2005; Goldenberg, 2000; Zukerman, 1989)

Definitions

• Infant Mortality: The death of an infant before his or her first birthday.

• The infant mortality rate is, by definition, the number of children dying under a year of age divided by the number of live births that year. – Neonatal Deaths: (Further division) Number of

deaths during the first 28 completed days of life per 1,000 live births in a given year or period.

Background

• Wise & Pursley (1992) state that infant mortality rates are a kind of “social mirror” that reflect broad inequalities in society and illuminate the social injustice of communities.

Background

Problems: 2) Socioeconomic and Behavioral factors

A major contributing factor to these poor outcomes of pregnancy is poor socioeconomic/ behavioral circumstances affecting the access that vulnerable populations have to the healthcare system in this particular county.

Court Involved Population

• Often mirrors larger population for poor outcomes

Drug Court• Drug courts are judicially supervised court dockets

that handle the cases of nonviolent substance abusing offenders under the adult, juvenile, family and tribal justice systems.

• Drug courts operate under a specialized model in which the judiciary, prosecution, defense bar, probation, law enforcement, mental health, social service, and treatment communities work together to help non-violent offenders find restoration in recovery and become productive citizens. In the USA, there are currently over 2,140 drug courts representing all fifty states.

Savings• The cost savings for drug courts are impressive, with cost savings ranging

from nearly $3,000 to over $12,000 per client, additionally • Those who graduate from drug courts have lower recidivism rates than

offenders who do not go through a drug court program (Roman et al. 2003; Aos et al. 2006).

• This research also shows that because of the integration of numerous systems, graduates of drug court are able to interact more effectively with the community when they have access to health care, educational/job training, and treatment modalities.

Lacking

• What was lacking was the health care aspect of the drug court system.– Women giving birth on methadone– Suboxone use (under studied)

• Suboxone, in particular was problematic because it is under studied in terms of use during pregnancy, clinical trials are ongoing for neonatal dependency withdrawal and the use is under reported (Clinicaltrials.gov. 2009. NCT00521248; McNicholas Laura 2008).

– Created a situation for relapse and difficulty with program compliance

Area Under Study

Perfect Opportunity

• In past, focus on reducing infant mortality has been on prevention and treatment programs for prenatal care.

• No improvement despite numerous efforts

Solution: Patient Navigation Program

New Approach

• The program is titled, “Patient Education and Navigation for High-Risk Women.” This program builds upon research done by Olds et al (1986) that showed evidence for the effectiveness of nurse home visiting during pregnancy for improved birth outcomes among disadvantaged women. The concept of individualized nursing care is implemented as an intervention in the form of patient navigation; individualized to meet the needs of every client.

Research Questions

• Does individualized navigation impact the rate of preterm births?

• Does patient navigation impact the rate of low birth rates?

• Does patient navigation assist with program compliance?

• Does patient navigation assist with socialization and subsequent success?

Goal of Study

• Evaluation of program in order to create a sustainable model of health care through the justice system– Socialization considerations rather than

resocialization

To explore the health care experiences of this group of at-risk women and examine how this group of people manage to obtain health care within a system that has historically discriminated against them.

Design• Initial design included only pregnant women• Design was amended to include women who were

parenting children under the age of five• Design was amended again to include the stakeholders

The process of data analysis is like a funnel: Things are open at the beginning (or top) and more directed and specific at the bottom. The qualitative researcher plans to use part of the study to learn what the important questions are. He or she does not assume that enough is known to recognize important concerns before undertaking the research. (Bogdan & Biklen, 1998, p.7)

Methods

This project was a qualitative evaluative study using open ended interviews that were audio-taped and transcribed.

The interview process consisted of two hour interviews that varied slightly from interview to interview and built on each other. I approached “the data with an eye to letting them teach me what was important” (Bogdan & Biklen, 1998, p. 32).

Methods

• Primary Data SourcesWomen (pregnant or parenting), n = 47

Secondary data sourcesInfectious disease specialist, n = 1Navigation Nurse, n = 1Family practice physician, n =1Family Court Social Worker, n = 1Patient Navigation Social Worker, n = 1The observations took place at three locations: a clinic designed to promote treatment and drug adherence, individual appointments with the women and their OB/GYN provider, and the Syracuse Community Treatment Court (SCTC)

Profile

• Between 4/01/07 and 4/01/08 there were 192 women enrolled in the SCTC.

• Approximately 32% of these women were identified as African-American, 39% were Caucasian, 3% were Native American, 4% were Hispanic, and 4% were identified as other race/ethnicities, with the remaining percent missing this data.

• The women selected for the study roughly reflected the demographic data for the enrollment in SCTC (15 women African American, 21 women Caucasian)

Results• All participants had a history of child welfare involvement. Over half of the participants had one or

more children in foster care and one or more children living with them. Some spent time in the foster care system during their youth while others have been separated from their children; many fall into both categories.

• Transportation was a challenge for participants - few own their own vehicle and public transportation was difficult to navigate due to bus schedules and the lack of a cross-town bus in this particular city.

• Safe, stable housing was both difficult to find and financially difficult to attain.• Participants overwhelmingly stated that they wanted to “become a better parent.” One client

stated: “I messed up with my other kids and lost them to foster care. I don’t want to lose these kids.”

• Participants desire stable jobs and/or continuing education, and the majority state that they are “fearful of receiving state benefits” for a long period of time.

• Participants appear resilient despite having faced many challenging and traumatic events.• Participants are challenged by financial situations, exacerbated by limited education, lack of child

care, difficulty managing medical care, and public benefits. • Primary source of health care prior to intervention by nurse navigator was the free health clinic.• Time horizon is different for this group of women and supports the concept of a time horizon that

is differentiated by class (Payne, Ruby, 2006). This group of women tend to think of the “here and now” and this focus on the present hinders them from seeking preventive health care, especially prenatal care.

Outcomes• There is little doubt that housing had a positive impact on the participants, but securing permanent

housing was difficult for most of the participants. Proper housing appeared to be related to compliance with many of the program requirements.

• Participants who were eligible for program housing during treatment found that it positively affected other areas of their life, such as reducing stress and the ability to remain compliant with the requirements of the program.

• Participants also stated that being able to keep their children with them made it much easier to remain compliant. The participants who did have their children with them stated that having a “room for each child” was the most important aspect of permanent housing and they saw this as their goal for long term housing options. They felt that by providing a better environment for their children, this allowed them to provide “the experience of childhood” that many said they had not experienced in their own lives or with their first set of children.

• Participants related that they would not have been able to manage their health care without the assistance of the nurse navigator. All pregnant participants interviewed, who used the nurse navigator, stated that they felt that the nurse was able to “talk to the doctor” for them and “get me the help I need”.

• All pregnant participants interviewed stated that the nurse navigator was able to get them into “regular” health care and away from the “poor people’s clinic”. This reference is to the health clinic that represented the main source of health care delivery for this group of women prior to intervention by the nurse navigator.

Cost

• Published online July 2, 2007• PEDIATRICS Vol. 120 No. 1 July 2007, pp. e1-

e9 (doi:10.1542/peds.2006-2386)• Cost of Hospitalization for Preterm and Low Birth Weight Infants in the United

StatesRebecca B. Russell, MSPHa, Nancy S. Green, MDa,b,c, Claudia A. Steiner, MD, MPHd,

Susan Meikle, MD, MSPHd, Jennifer L. Howse, PhDa, Karalee Poschman, MPHa, Todd Dias, MSa, Lisa Potetz, MPPa, Michael J. Davidoff, MPHa, Karla Damus, PhD, RNa,c, Joann R. Petrini, PhD, MPHa,c

Cost• RESULTS. In 2001, 8% (384200) of all 4.6 million infant stays nationwide included a diagnosis

of preterm birth/low birth weight. Costs for these preterm/low birth weight admissions totaled $5.8 billion, representing 47% of the costs for all infant hospitalizations and 27% for all pediatric stays. Preterm/low birth weight infant stays averaged $15100, with a mean length of stay of 12.9 days versus $600 and 1.9 days for uncomplicated newborns. Costs were highest for extremely preterm infants (<28 weeks’ gestation/birth weight <1000 g), averaging $65600, and for specific respiratory-related complications. However, two thirds of total hospitalization costs for preterm birth/low birth weight were for the substantial

number of infants who were not extremely preterm. Of all preterm/low birth weight infant stays, 50% identified private/commercial insurance as the expected payer, and 42% designated Medicaid

• CONCLUSIONS. Costs per infant hospitalization were highest for extremely preterm infants, although the larger number of moderately preterm/low birth weight infants contributed more to the overall costs. Preterm/low birth weight infants in the United States account for half of infant hospitalization costs and one quarter of pediatric costs, suggesting that major infant and pediatric cost savings could be realized by preventing preterm birth.

DiscussionProgram’s stated goals:• We have developed and are using a database to track our test results.

– For Objective #1The clients scored an average of 2.1 (out of a possible 5 points) on the pretest and an average of 4.5 (out of a possible 5 points) on the posttest. Overall, 83% of participants scored higher on the posttest than on the pretest.

• – For Objective # 2, for the time period from 2/1/09 – 2/24/10, 20% (19 out of 97) of the new clients reported

use of folic acid upon initial interview. (See attached survey instrument). From February 8, 2010 through February 24, 2010, 22 of the current program participants were contacted and asked about their use of folic acid. 17 women, (77%), report ongoing use of folic acid.

• – For Objective #3: Since 2/1/09, 19 program participants reported being pregnant. Of this group, all of the

women reported having a medical home; however, due to their expressed dissatisfaction with their care, we assisted in finding new providers for 2 of the women.

• – For Objective # 4: For the time period of this report, clients scored an average of 3.0 (out of a possible 5

points) on the pretest and an average of 4.1 (out of a possible 5 points) on the posttest. 67% of participants scored higher on the posttest than on the pretest.

• – For Objective #5: At this time, 100% of infant children of the program participants have a medical home.

• Main problem is sustainability

Emerging Trends

• This preliminary work has shown that resocialization efforts often fail because basic socialization for this group has never occurred. More work needs to be done in this area in order to consider these factors of unequal distribution; taking a multidimensional approach to health care disparities in this community would provide opportunities for successful socialization.

Future Model• By taking a multidimensional approach to the

health disparities and the related outcomes noted in this group of women, a housing facility could be developed that would promote the health care advocacy and socialization process that is needed for this vulnerable population. One-on-one mentoring, including accompaniment to office visits by staff, would provide one avenue of advocacy that could be used as a teaching tool for improved outcomes, further empowerment, and obtaining social capital.

Social Cohesion• Speer, et al. (2001) found that, social cohesion is related to intrapersonal

empowerment with empowerment being “an intentional ongoing process centered in the local community, involving mutual respect, critical reflection, caring, and group participation, through which people lacking an equal share of valued resources gain greater access to and control over those resources”

• This is a useful concept because it focuses on the community as well as the individual; a critical element of holistic empowerment and successful socialization. Partnerships with local community groups to provide mentoring would be a useful tool that might assist with socialization. Basic living skills would be taught in a family type atmosphere that would benefit both parent and child.

Schematic Framework of Constrained Choice

SOCIAL POLICY

COMMUNITY ACTIONS

WORK &

FAMILY

BIOLOGICAL PROCESSES (e.g., Stress Responses)

HEALTH OUTCOMESMORBIDITYMORTALITY

INDIVIDUAL CHOICES (e.g., Health Behaviors)

Decisions and Actions by Families, Communities and

Governments Can:• differentially affect men’s and women’s

choices and opportunities • impact stress levels and exposure to

risks• create incentives and disincentives for

engaging in health behaviors

Links Between Choice, Constraints, and Cumulative Impact on Health

Broader social context and individual “choice”

Jobs and Careers• Marriage, Family, Children• Neighborhood and Housing• Amount and Use of Income• Intergenerational Support

Constrained Choice and Rational Actions

• People construct choices from priorities and values (perception of options)

• Constrained choices shaped by context(s) and meanings

• Go beyond economic and psychological models of rational action

• Rational people make choices that don’t maximize their health

Why Gender and Constrained Choice Matter

• Gender differences in health are distinct from racial and SES disparities

• Knowledge gaps hamper intervention

• Need health consciousness in decision making at each level from individual to all policy realms

Summary of Argument• Biology interacts with social environment

• Social factors pattern the health trajectory

• Constrained choice shapes opportunity to pursue health

• Need cross-disciplinary collaboration to advance health of both men and women

New Approach

• Patient Centered approach• Patient Navigation• Housing • Socialization

Abstract The purpose of this paper is to describe a unique and innovative program that uses an encounter with the justice system to offer a health care plan for a subset of people going through drug court. With the application of social theory to clinical practice, an intervention in the form of patient navigation is developed in order to meet the needs of these clients. The paper offers a description of the program and evaluation tools that may be used for standardization and subsequent replication of this patient navigation model to improve negative birth outcomes. Constraints on choice may be used to explain the process of health care decision-making for this subset of people going through a court mandated drug program. Considering the effects of constrained choice as documented by Bird and Rieker (2008), a model program was developed providing evidence of an increase in program compliance for drug court clients and a reduction in the negative health outcomes for this group of at-risk people. Patient navigation within the framework of the constrained choice model offers a cost effective means of improving health care outcomes for vulnerable populations.

Future

• Grant is currently being written in conjunction with a social recovery piece

• Plan is to implement this in the Brooklyn Drug Court in Brooklyn, NY

• Researchers from Bentley University, Fordham, NYU, BU, and NDRI are participating

New Program to ImplementThe broad goal is to manualize an innovative program for substance-abusing parents with a holistic model aimed toward establishing healthy families. We integrate two pilot tested programs used in drug court settings for substance-abusing adults. The specific aim is:To integrate a health intervention with a social capital model for court-involved women of child-bearing age and men and women who are parenting children under five with the goal to:a) reduce negative birth outcomes b) increase family education with a focus on early childhood development c) reduce recidivism d) reduce relapse ratese) increase social capital networksf) prevent infectious diseases associated with drug use, (HIV/AIDS/HCV)

Review of Program

• PIC tool• Pre and post testing• Daily activities• Clients

PIC tool

• PreConception/Interconception Health• We believe that all people deserve quality medical care. We

are giving this form to you today to provide you with information about factors that can influence your health, and possibly influence future pregnancies. About half of the poor outcomes of pregnancy are determined by risk factors that may be correctable before pregnancy. This checklist is a way to help identify and thereby minimize those risks. This form is meant to provide you with talking points to be discussed with your medical provider. We are happy to go over the definition of terms however we cannot give medical advice. If you wish, we can assist you in scheduling a medical appointment.

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