Appendix B - Additional tier 2 strategies supported by coalition members
Additional Tier 2 Strategies Supported by Members of the Coalition: Changing the Context
D. Establish a statewide community health worker system similar to the one in Massachusetts: this can include models involving lay home visitors, community doulas, preconception peer educators, peer breastfeeding counselors, oral health, etc.
E. Engage in a broad effort to change the language of mental health to reduce fear and increase incidence of provider-patient communications about mental health needs, “stress”, “stressors”, and “stressful events/situations.”
F. Expand the Person-Centered Care Model (PCCM) to include women’s health, including oral health, with a Life Course approach.
G. Expand state Husky to undocumented women and their families.
Strategy 2D: Establish a statewide community health worker system similar to the one in Massachusetts: this can include models involving lay home visitors, community doulas, preconception peer educators, peer breastfeeding counselors, oral health, etc.
Massachusetts is the first state in the country, via the Economic Opportunities Act of 1964, to recognize and support the unique role community health workers offer isolated families and/or those confronting language and cultural barriers. Community health workers are employed by a number of organizations to work within the neighborhood in which they live. They reflect their neighbors’ ethnicity and culture, which helps to establish trusted communication and relationships. In addition to navigating various health and human service systems to ensure that children and families have access to needed resources, they also help facilitate communication between health care providers and their patients. In Massachusetts some of the organizations that employ community health workers include: the Boston Association for Child Birth Education; the Lowell Community Health Center; The YWCA of Central Massachusetts; the Stanley Street Treatment and Resources (STARR); The Pioneer Valley Area Heath Education Center, a program of the Springfield Department of Health and Services. Connecticut, the country (specifically through provisions contained in the Affordable Care Act), and global public health initiatives have recognized the value of community health workers. This awareness is reflected in the On the Ground Examples listed below and offer the Coalition the opportunity to explore the feasibility of creating opportunities for community health workers and to determine the infrastructure needed to support them.
Strategy 2D: Examples from the ground
Connecticut’s Area Health Education Center’s (AHECs) Support of Community Health Workers (CHWs)
Connecticut AHECs recognize the important role community health workers provide in linking those in need of care and services to the resources available in a timely and supportive manner. Over the years, AHECs’ support of community health workers have included:
Developing a curriculum for community health outreach workers;
Surveying, via the Southwest AHEC, CHWs and their employers. These surveys were done in order to obtain information on the roles, activities, training needs and employment security of CHWs in Connecticut; and
Identifying potential employment opportunities for CHWs under health care reform legislation as well as through other federal initiatives, such as The Center for Medicare & Medicaid Innovation (the Innovation Center) and state policy initiatives through the Centers for Disease Control and Prevention (CDCP) and Health Resources and Services Administration (HRSA).
“Community Ambassadors” are mothers from New Haven trained in brief mental health intervention, key principles to promote health, development and achievement across generations, act as referral sources to the MOMS hubs which 12 different areas of New Haven that were identified as having the most need for services. A comprehensive workforce development strategy will be utilized to train all outreach workers at existing neighborhood and citywide agencies in key principles of a two generation strategy to promote health, development and achievement. All neighborhood business professionals frequently interacting with mothers (referred to as “door openers” (e.g. nail technicians, hair dressers, and laundromat owners) will be trained on brief “touch points” to use to engage mothers with the neighborhood MOMS hubs. In this way, a large portion of the neighborhood or community would become “mom informed” and filter families at risk or in need to the MOMS hubs.
The Bridgeport Alliance for Young Children (BAYC)
BAYC is a city-wide collaborative of parents, residents, elected officials, and providers. BAYC helps families find community resources; advocates for families with young children; and acts as a source of knowledge and experience on early childhood topics. “Community Messengers” is a BAYC program that provides parents with the opportunity to help other parents across the city through face-to-face communication. The Community Messengers program was started as a city-wide grassroots vehicle of communication across neighborhoods. Agencies use multiple means of communication…telephone, newspapers, computers, radio and television but parents have said the best way to communicate is by talking…to neighbors, to children, to doctors, teachers and family. Bridgeport parents are trained to know about community resources and educated about early childhood topics so they in turn can teach other parents.
Strategy 2E: Engage in a broad effort to reduce maternal fear and stigma about the spectrum of emotional and psychological complications of pregnancy and childbirth by increasing provider- patient communications, including perinatal mental health in childbirth education programs, raising public awareness, and developing a coordinated system of treatment and care.
The perceived stigma of having a mental health challenge is particularly difficult for pregnant women or new mothers, who may be reluctant to disclose feelings of depression, dependence on substances and/or living in an abusive situation for fear of being considered an “unfit” mother. In addition to changing the language and understanding of mental health disorders, it is equally important that those to whom women may disclose are knowledgeable and trained in providing support, care and the services that are needed.
There are a number of resources addressing the stigma of mental health and offering support and guidance around provider/patient communication related to issues of toxic stress, maternal depression, and trauma.
Strategy 2E: Examples from the ground
Connecticut Chapter of the National Alliance on Mental Illness (NAMI)
CT NAMI has been operating in the state for over 30 years. It offers support, education and advocacy related to mental health concerns to family members, people living with mental health challenges and the community at large. Trainings offered by CT NAMI include:
Perspectives – a free one-day course focuses on mental illness education and client/provider/family member collaboration skills. The program targets “front-line” mental health provider staff and presents family members as key natural supports to enhance a treatment plan and is aligned with the recovery model supported by DMHAS.
Sharing Hope – a free interactive educational presentation that aims to decrease mental health stigma in the African-American faith community and the Latino community in general to increase awareness of mental health recovery, and to introduce NAMI education and support programs. The program is presented by a panel of individuals with the lived experience of mental illness and family member experience. This presentation is available in both English and Spanish.
The following strategy goals were cited in the organization’s 2013 Annual Report:
Reach out to underserved areas and constituencies, increase engagement and participation.
Strengthen advocacy around mental health. Expand advocacy . . . in the private mental health system as well as the public.
Develop mission-focused marketing and communications to raise visibility.
Improve reach, quality and impact of marketing and communication, including social media.
The Connecticut Women's Consortium
This organization strives to ensure that the behavioral health system responds to the needs of women and the people and organizations that affect them. The Consortium is recognized for the trainings it offers in all aspects of the behavioral health needs of women with a particular focus and expertise in trauma. In addition to the trainings, the Consortium produces a Trauma Matters newsletter. Since 2002, the Trauma Matters newsletter has provided information about trauma and trauma-informed care by examining best practices and efforts in behavioral health in the state of Connecticut.
Strategy 2F: Expand person-centered care model (PCCM) to include women’s health, including oral and mental health, with a lifecourse approach.
The state of Connecticut was among the sixteen state recipients of a multi-million dollar, multi-year State Innovation Model (SIM) grant from the Centers for Medicare and Medicaid Innovation (CMMI) with the purpose of improving health care outcomes and eliminating health inequities, while reducing health care costs. As part of this innovation-driven funding opportunity, Connecticut is positioned to shift from a volume-based system to a value-based payment system for medical care reimbursed by Medicare, Medicaid, and private insurers. The vision for the Connecticut SIM project strives to achieve a “whole-person-centered system” that integrates and coordinates primary care, oral health, behavioral health, consumer engagement, community support, and public health. The concept of “whole person- centered care model” includes comprehensive assessments of the individual person and of her family to identify strengths, capacities, risk factors, behavioral health, comorbidities, and the ability to manage self-care. It also addresses cultural, linguistic, health literacy barriers to care in order to develop an appropriate person-centered care plan by using shared decision making tools.
It is with our shared public and clinical health expertise that members of the Coalition to Improve Birth Outcomes recommend that the Connecticut SIM project actively seek to include women’s health issues and related supports and care throughout the life course, in an effort to align clinical care recommendations with evidence-based public health strategies to improve birth outcomes and reduce disparities. By leveraging innovative health information technology and coordinated health care processes, to include critical and holistic women’s health outcomes, care, and services throughout a woman’s life course, the Connecticut health care system can increase its effectiveness in preventing and treating early-stage conditions that have the potential of deteriorating, while significantly impacting women, the health of their offspring, and the overall burden on our state’s health care system.
Strategy 2F: Examples from the Ground
Given the innovative and recent nature of the State Innovation Model project, there are currently no distinguishable examples that can be shared at the time of this writing. Evaluation results from similar projects in Connecticut and other states will be shared as they become available.
Strategy 2G: Expand state Husky to undocumented women and their families.
There are over 11 million people in the US who are unable to purchase health insurance from the state exchanges, under the Patient Protection and Affordable Care Act of 2010. Many of these individuals, who are undocumented immigrants, also continue to be excluded from Medicaid coverage and most other entitlement programs.113 Approximately 4 million US-born children have undocumented parents.113 Health care providers are continually faced with ethical dilemmas when it comes to caring for members of these populations, and countless women continue not to have access to valuable preconception, prenatal care, postpartum, and interconception health care services, despite the best available evidence and recommendations supporting the value of such care.
In order to get federally- and state-funded Medicaid and Children Health Insurance Program (CHIP) coverage, most Legal Permanent Residents (LPRs) or green card holders have a 5-year waiting period. States may remove the 5-year waiting period and cover lawfully residing children and/or pregnant women.
The state of Connecticut has joined the 25 other US states that chose to provide Medicaid coverage to lawfully residing immigrant children and/or pregnant women without a 5-year waiting period. People who aren’t eligible for Medicaid because they don’t have eligible immigration status may get Medicaid coverage for limited emergency services, if they otherwise meet other Medicaid eligibility criteria. Women who fall into this category in Connecticut can receive intrapartum care during labor and delivery under this provision, but are not able to receive prenatal or postpartum care coverage.114
In the absence of an established safety-net for uninsured individuals who do not otherwise have access to health insurance coverage or affordable care, efforts have sprung up across the nation and our state to attempt to fill a gap in the provision of preventive and acute care. An example is the HAVEN Free Clinic which has been operating since 2005 as a student-run primary care clinic partnered with Fair Haven Community Health Center (FHCHC) and Yale University. Operating four hours per week, the model includes volunteer students and providers across the disciplines of medicine, nursing, physician’s associates, and public health, and is able to serve individuals between the ages of 18 and 65 living in the Fair Haven neighborhood. While women served by this clinic cannot receive prenatal care, they can receive other reproductive health care services including family planning education and counseling, screenings for sexually transmitted infections, and more. While the effort is laudable, its reach is limited and too many still remain without access to care. To further ensure that birth outcomes improve for all populations in our state, including for those Connecticut newborns whose mothers are foreign-born and lack legal residence or American citizenship status, the Coalition recommends that actions be considered at the state level to ensure that ALL women have access to care throughout their life course, regardless of documentation status.
Strategy 2G: Examples from the Ground
Prenatal Care Services through Medicaid
New York State has developed a comprehensive prenatal care program that offers complete pregnancy care and other health services to women and teens who live in New York State and meet Medicaid income guidelines. Health insurance is available for pregnant women regardless of their immigration status. Under Prenatal Care Services, pregnant women receive prenatal health services, such as lab tests, HIV tests, nutrition screenings, and other services related to their pregnancy and for at least two months after delivery. Babies receive health care services for at least one year after birth.
Family Planning Extension Program
The Family Planning Extension Program (FPEP) extends access to family planning services to postpartum women residing in the state of New York, regardless of immigration status, for up to 26 additional months. Women are eligible if they were on Medicaid while they were pregnant, but lost Medicaid coverage when the pregnancy ended.