Changing the context: Improving health outcomes by making healthy choices the easy choice.
It is unreasonable to expect people to change their behavior so easily when so many forces in the social, cultural, and physical environment conspire against change.
-Institute of Medicine (IOM)
When we change the environment to promote and encourage healthy behaviors we not only impact individuals, we also improve the overall health of our communities. Interventions that change the environmental context to make healthy options the de- fault choice, regardless of education, income, service provision, or other societal factors have the potential to greatly improve the health of expectant mothers, infants and families the most. The defining characteristics of these interventions are that individuals would have to expend significant effort not to benefit from them.
Tier 2 Recommendations: Changing the context
A. Establish and evaluate pilot projects involving holistic MCH medical home models
B. Integrate mental and oral health into hospital-based perinatal education models, group
prenatal care, as well as home visiting programs.
C. Create trauma-informed environments for pregnant women, infants, and their families.
Recommendation 2A: Establish and evaluate pilot projects involving holistic MCH medical home models.
A patient-centered medical home for pregnant women and their children is not a new concept, yet it continues to be a powerful one ripe with potential for sustaining healthy families. In the 2012 Compendium, AMCHP recommends service integration for women and infants that provide comprehensive, coordinated, culturally sensitive care where a trusting partnership can develop between a patient and their health care providers. Having medical, mental and oral health services at one location, sharing medical records, and integrating services, provides easy access to a coordinated system of care. Modifying processes in an effort to eliminate scheduling, reimbursement, and information sharing-related barriers that currently contribute to a separation of care between a mother and her children, as well as between disciplines and providers, can also provide an opportunity to better care for families across the continuum of time and along the wide spectrum of developing needs. The holistic medical home model also provides more opportunities to integrate other services such as prenatal education, support groups and wrap-around services for housing, transportation, childcare, active living, healthy eating, or other “whole person, whole community” needs.
Recommendation 2A: Emerging and promising examples
DC Developing Families Center (DFC)
The Developing Families Center (DFC) promotes the empowerment of low-income families through the collaboration of three nonprofit service providers: the Community of Hope/Family Health and Birth Center, the Healthy Babies Project and the United Planning Organization Early Childhood Development Center. The DFC offers comprehensive, one-stop, family-centered women’s and children’s health care, child care services, family resource and support services, confidential counseling, and adult education. Some of the services offered are prenatal and birth care, immunizations, childbirth education, optional out-of-hospital birth settings, Medicaid enrollment, postpartum care, breastfeeding education, family planning, STI screening, case management, nurse home visits, teen and Black Parenting programs, fatherhood programs, social service assistance and early childhood age-appropriate education. The model also incorporates community members through a Community Advisory Board that meets monthly to recommend changes and discuss new policies.
PCC Community Wellness Center
Located throughout the Westside of Chicago and nearby suburbs, the PCC Community Wellness Center network of community-based wellness centers provides comprehensive coordinated care to families regardless of ability to pay. Services and programs include primary care, midwifery, oral health care, behavioral health care, Centering Pregnancy, Reach Out and Read, outreach and enrollment, and a local fresh produce market.
Clifford Beers Clinic: Integrated Family Center for Chronically Stressed Families, New Haven, CT
The Clifford Beers Clinic is adopting an integrated approach to the delivery of pediatric and family focused health and mental health to reduce the lifelong health implications of stress. By utilizing a comprehensive, trauma-informed care model, providers will be able to efficiently integrate the social, mental and physical health needs of children and families. This allows them to account for past experiences that may be affecting health by applying aspects of Life Course Theory and the Health Home model.
Community Health Centers Leveraging the Social Determinants of Health.
Community-based health centers have enormous potential when it comes to engaging local communities across the life course continuum and with a holistic, wrap-around approach. In partnership with the National Association of Community Health Centers and with support from the Kresge Foundation, the Institute for Alternative Futures developed a report, a database of efforts, case studies, and a set of recommendations for CHCs and others on how to support and expand efforts to leverage the social determinants of health. For a 2-page handout about the project and report, click here. You may also find the full report and a literature review from the Clinical Directors
Recommendation 2B: Integrate mental health, oral health and wellbeing into hospital-based perinatal education models, group prenatal care, as well as home visiting programs.
Integrating mental health, oral health and wellbeing into hospital-based perinatal education models, group prenatal care and home visiting programs will raise awareness about the importance of screening for and addressing these needs in pregnant women. This integration supports the continuum of care model that has proven effective in improving the health of the patient, patient satisfaction, and a reduction in per capita cost (IOM.gov).
Home visiting programs build upon decades of scientific research, which shows that home visits by a nurse, social worker, or early childhood educator during pregnancy and in the first years of life improve child and family outcomes. Home visits prevent child abuse and neglect, encourage positive parenting, and promote child development and school readiness. According to a recent Pew Charitable Trusts study, every dollar invested in home visiting yields up to a $9.50 return to society.34
Home visiting programs provide an unprecedented opportunity to reach families and communities at- risk for health disparities. Evidence-based home visiting models address physiological, social, psychological, economic, family and other factors that influence children’s health and development.
Recommendation 2B: Emerging and promising examples
The Nurse-Family Partnership (NFP)
NFP is designed for first-time, low-income mothers and their children. It includes one-on-one home visits by a trained public health registered nurse to participating clients. The visits begin early in the woman’s pregnancy (with program enrollment no later than the 28th week of gestation) and conclude when the woman’s child turns 2 years old. NFP is designed to improve (1) prenatal health and outcomes, (2) child health and development, and (3) families’ economic self-sufficiency and/or maternal life course development. The US Department of Health and Human Services (DHHS) created the Home Visiting Evidence of Effectiveness (HomVEE) in 2009 to conduct a thorough and transparent review of the home visiting research literature. In 2013, HomVEE reviewed the evidence of effectiveness for specific home visiting program models. The NFP model had favorable impacts in 7 of the 8 outcome domains, the second highest rating of the 14 DHHS approved evidence-based home visiting program model. The State of Connecticut chose NFP as one of the evidence-based models to be supported through the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Programs federal funding initiative. To learn more about how NFP is being implemented in Southeastern
Connecticut, visit VNA of SC.
The Perinatal & Infant Oral Health Quality Improvement Intensive Community Outreach Project
A collaboration between the CT Dental Health Partnership and the CT Department of Social Services, the PIOHQI/ICO project’s purpose is to provide a coordinated approach across Connecticut that addresses the comprehensive oral health needs of pregnant women and infants most at risk, supporting an environment that seeks to eliminate oral health barriers and disparities.
The CT Dental Health Partnership (CTDHP) currently provides outreach to at-risk pregnant women and young children in Connecticut who are not in regular preventive oral health care through an existing, state-supported pilot project that serves women and children in two cities. This pilot, which works through medical providers as well as oral health providers, is based on the Trusted Person model, will
be expanded statewide, and has the potential for national replication.
The New Haven Mental Health Outreach for Mothers (MOMS) Partnership is a community-academic partnership between All Our Kin, Clifford Beers Clinic, New Haven Health Department, New Haven Housing Authority, New Haven Healthy Start, The Diaper Bank, The CT Department of Children and Families, and Yale School of Medicine, with input from families and providers that seek to achieve the highest possible standards of mental health and well-being for New Haven women and their families. The MOMS theory of change rests on the premise that improvements in mental health for Mothers vastly improve outcomes for their children. Additionally, they believe that improvement in mental health is connected to addressing issues of lasting poverty alleviation and improving access to basic need resources and economic security.
DAWN (Depression Attention for Women Now)35
For many women, and particularly for underserved women, or those from socially disadvantaged backgrounds, their Ob-Gyn provider serves as their primary care provider. While Ob-Gyn providers increasingly accept their role as primary care providers, many feel they have inadequate training to screen and treat depression and that they lack adequate resources for follow-up care. Having a depression intervention based in Ob-Gyn clinics is an important and effective way to meet the health care needs for women. The key difference between DAWN and usual care/referral to specialty services is the integrated team approach, a standardized symptom assessment and tracking system, and the population-based view of care. The DAWN consultant team consists of the care manager, an Ob-Gyn provider and psychiatrist. This team reviews every patient on the care manager’s caseload each week. By discussing each patient, focusing on depression symptoms and behavioral changes, the team can be very responsive in making suggestions about additional behavioral techniques or modifications to medications. This intense approach provides consistency in review, and ensures that patients do not “fall through the cracks” because the care manager is contacting them frequently. This comprehensive approach does not rely on the patient making an appointment to come into the clinic, but on the care manager reaching out to the patient.
CenteringPregnancy SmilesTM (CPS)36 is a partnership between the University of Kentucky, Trover Health System, and Hopkins County Health Department. The purpose of the partnership is to: (1) establish an infrastructure to address health problems requiring research-based solutions, (2) develop a model for community partnership formation, and (3) address problems related to preterm births
and low birth-weight infants and early childhood caries in a rural, seven-county region in western
Kentucky. This area is below state and national norms in education level of the population, income, and oral and general health. The partnership implemented a new prenatal care model that significantly reduced preterm and low birth-weight births for participating women, thus significantly improving the infants’ health while saving an estimated $2.3 million dollars in health care costs for acute care of premature infants in this population and enabling the expansion of dental outreach services for children in Hopkins county.
Maternal and Infant Outreach Program (MIOP) and Comadrona
Administered by the Hartford Department of Health and Human Services (HDHHS) and the Hispanic Health Council, the Maternal Infant Outreach Program (MIOP), and its sister program Comadrona, provide outreach and prenatal care education and support in the Hartford community with the aim of identifying pregnant women early in their pregnancy and engage them in developing individualized care plans in partnership with other involved clinical partners. Pregnant and postpartum women are connected to the services they need. Home visits continue a minimum of one year after birth and children and their families are linked to pediatric care and other developmental and family resources.
MIOP has documented success in addressing key pregnancy and birth challenges:
Ninety percent (90%) of clients served in the HDHHS MIOP program initiated prenatal care during the first trimester compared to 77 % of all Hartford mothers who delivered in 2012;
The infant mortality rate (IMR) is consistently lower for MIOP participants than that of overall Hartford residents. From 2001-2012, the average IMR for women enrolled in the MIOP program is 1.8 infant deaths per 1,000 live births compared to the City’s average of 9.9 per 1,000 live births.
The low birth weight rate (<2,500 grams) among MIOP clients who delivered from January to September 2013 is approximately 10%, lower than the city’s annual rate of 11.3%.
Minding the Baby Home Visiting Program
Minding the Baby (MTB) is an intensive home visiting intervention working with first-time young mothers and their families in New Haven, CT. First developed in 2002, the program is interdisciplinary and brings together a home visiting team including a pediatric nurse practitioner and a licensed clinical social worker to promote positive health, mental health, life course, and attachments outcomes in babies, mothers, and their families. MTB clinicians provide direct service for your families while MTB researchers conduct ongoing research with both intervention and control families. MTB is a collaborative effort of the Yale Child Study center, Yale School of Nursing, Fair Haven Community Health Center, and Cornell Scott Hill Health Center.
In September 2014 MTB met the rigorous criteria required to be recognized by the Department of Health and Services (DHHS) as an evidence based early childhood home visiting model. This criteria has been established through DHHS’ Home Visiting Evidence of Effectiveness (HomVEE) review process. MTB is now sanctioned as an approved Maternal, Infant and Early Childhood Home Visiting (MIECHV) model that states can implement with federal Affordable Care Act funds that have been allocated to support home visitation programs. Minding the Baby joins Child FIRST as an early childhood home visiting model that was developed in Connecticut and recognized by HomVEE as being evidence based.
Recommendation 2C: Create trauma-informed environments for pregnant women, infants and their families.
Developments in neuroscience have taught us that adverse childhood experiences cause an outpouring of stress hormones that, over time, change the way the brain grows, develops, and reacts to the environment and to other people – even years down the line. Traumatic stress can create problems with forming relationships, regulating and controlling emotions, perceiving danger where there is none, and even physical health in adult life.
Currently, behavioral health and physical health treatment exist in separate treatment silos; clinical services and prevention services are fragmented and the individual is viewed in isolation from his/her family, environment and historical experiences. Adults and children referred for treatment often go untreated, in part due to missed appointments and poor follow up. Current medical and clinical services are not designed to address the complex needs of families living under chronic stress. A comprehensive and integrated model of trauma, and resilience-informed health care is needed to reduce the psychological, as well as biological stressors related to trauma, violence, and grief, and to stabilize families’ health and promote resilient environments for positive development.37
A trauma-informed approach to the delivery of health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. The four key elements of a trauma-informed approach are: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; (3) responding by putting this knowledge into practice; and (4) resisting re-traumatization.38
Trauma-informed care (TIC) is a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment. TIC is an approach to engaging individuals with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. The Coalition recommends the strengthening of a health care and supports system that promotes healing environments through embracing "key" trauma-informed principles of safety, trust, collaboration, choice, and empowerment. In addition, there must be the availability of evidence-based trauma-specific services and treatments to meet these needs throughout a person’s life course.38
Recommendation 2C: Emerging and promising examples
Clifford Beers Clinic: Integrated Family Center for Chronically Stressed Families, New Haven, CT
The Clifford Beers Clinic is adopting an integrated approach to the delivery of pediatric and family focused health and mental health to reduce the lifelong health implications of stress. By utilizing a comprehensive, trauma-informed care model, providers will be able to efficiently integrate the social, mental and physical health needs of children and families. Accounting for past experiences that may be affecting patients’ health care is applied through the lenses of the Life Course perspective and within a trauma-informed Health Home model.
Adverse Childhood Experiences Screening Tool (ACEs)
Adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and overall well-being. These experiences include, for example, abuse (physical, emotional, or sexual), parental divorce, and the incarceration of a parent or guardian. The National Survey of Children’s Health (NSCH) routinely collects ACEs data from a nationally-representative sample.39 The American Academy of Pediatrics (AAP) supports the use of the ACEs screening tool within the context of the pediatric medical home.40 To this end, it has launched the Resilience Project supporting pediatric primary care physicians in identifying, treating, and referring children and youth who have experienced toxic stress.
The goal of WSPIC is to improve the quality of services for women receiving substance abuse treatment in Connecticut, and thus the treatment outcomes, by participation in a recovery-oriented treatment system of care, incorporating current best practices in gender-responsive and trauma- informed programming. Through this initiative, there was increased interaction and knowledge exchange between community-based service providers, persons in recovery, the research community and policy-makers. Through the WSPIC initiative, three products have been developed.
Bayview Child Health Center, San Francisco, CA
The Bayview Child Health Center has taken a comprehensive approach of trauma-informed care to treat residents of a low-income area. After identifying the many social and emotional experiences affecting many of the patients of the clinic, they developed an interconnected model of care that recognizes trauma and social stressors as risk factors, and analyzes them in conjunction with physical presentation of illness. This comprehensive approach stimulated the development of the Center for Youth Wellness where they continue to practice trauma-informed interventions. This may serve as a model for other Connecticut providers serving similar populations.41
Developing Trauma-Informed Organizations
The Institute for Health and Recovery offers a toolkit designed to help organizations improve the quality of services by integrating an understanding of the impact of trauma and violence into their policies and procedures. For information on the new second edition of this toolkit, go to IHR’s website www.healthrecovery.org/toolkit
Please refer to Appendix B for additional Tier 2 strategies supported by Coalition members.