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Tier 4:
Ongoing clinical interventions: evidence-based Interventions within clinical settings

In addition to ensuring that women are healthier throughout their life course and within their communities, an effective maternity health care system should be adequately equipped with the tools and processes necessary to provide equitable access to evidence-based interventions within clinical settings. Ensuring that pregnant women are able to initiate early holistic prenatal care and be connected to other services, continues to be a priority for the state Connecticut.


To this end, Medicaid payment policies that incentivize early initiation into prenatal care have been highly successful. Many programs, like California’s Comprehensive Perinatal Services Program (CPSP) pay participating providers a bonus for eligible patients who enter prenatal care before 16 weeks.


Health Information Technology (HIT) tools such as electronic medical records (EMRs) or patient registries that document and track prenatal care entry and support data reporting have also been successful in getting women enrolled in prenatal care early in their pregnancy. Moses Lake Community Health Center, a large rural FQHC in Washington, uses its EMR system to facilitate early entry into prenatal care by recording pregnancy diagnoses, tracking prenatal care initiation and pregnancy risk status, and facilitating follow-up with patients to ensure care is timely and comprehensive.


In 2013, the Connecticut Department of Social Services introduced a Pay for Performance (P4P) Program in obstetric care. The purpose of this program was to improve the care for pregnant women and the outcomes of their newborns covered under the HUSKY Health programs. A total of $1.2 million was appropriated by the Connecticut General Assembly (CGA) to be paid to providers of obstetric care in the state fiscal year 2015. Obstetrical P4P payments are in addition to current fee for service payments. Connecticut focused on the following: timely completion (within 14 days) of online obstetrics prenatal and post-partum notification forms, first obstetric visit within 14 days after confirmation of pregnancy, at least one postpartum visit within 21 – 56 days after delivery, full-term, vaginal delivery after spontaneous labor whenever medically possible and the appropriate use of 17-alpha hydroxyl- progesterone when there is a prior history of spontaneous singleton preterm birth (prior to 37 weeks.) The temporary nature of this trial program contributed to the termination of reporting, once funding elapsed in 2014. The Coalition is recommending that providers be encouraged to reinstate their notification efforts so that Husky-covered pregnant clients may be connected to needed services and care in a timely manner.

Tier 4 Recommendations: Ongoing Clinical Interventions


A.  Support the provision of behavioral health services and oral health care throughout the life course and during the perinatal period.

B.  Integrate into provider training mental health, social stressors, and trauma education relevant to infants and families.

Recommendation 4A: Support the provision of behavioral health services and oral health care throughout the life course and during the perinatal period.

One in four adults in the US suffers from mental health disorders, often presented with preventable physical comorbidities.54 When primary care and behavioral health care are not integrated, people suffering from these conditions may not receive effective quality care and treatment. Research has shown that a number of people with diagnosable mental illness are reticent to seek services in behavioral health care facilities because of the stigma associated with mental health disorders.54

Practices that have been able to successfully co-locate services, have documented increases in behavioral health care utilization rates.54 Evidence supports the integration of primary and behavioral healthcare as a means for increasing access to whole-person quality care and improving overall health outcomes.55 Similar patterns have been observed in regards to oral health care, particularly as it relates to lack of access to quality and affordable oral health care on the part of women during the perinatal period. Research suggests that poor oral health care during pregnancy can increase the risk of poor birth outcomes, including low birth weight and preterm birth, as does untreated mental illness or behavioral health issues such as drug and alcohol abuse.56 Additionally, conditions affecting women during the perinatal period, and not dealt with appropriately have been shown to increase health risks for young children as well.57


In addition to continuing to support health promotion efforts targeting consumers, the Coalition recommends that Connecticut providers, health care payers, leaders and legislators engage in processes intended to ensure that the person-centered medical home model include the provision of integrated holistic care, inclusive of oral and behavioral health care, throughout a person’s life course in order to increase access to a high quality integrated care system, while reducing preventable poor birth outcomes associated with suboptimal access to quality behavioral and oral health care.57,58

Recommendation 4A: Promising and emerging examples

SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)

CIHS collects and shares a host of evidence-based information, tools, and promising models for provider organizations to draw upon as they design and implement integrated primary and behavioral health care services in their communities.


HRSA Integration of Oral Health and Primary Care Practice

The Integration of Oral Health and Primary Care Practice initiative seeks to expand oral health clinical competency among primary care providers as a means to improve access to early detection and preventive interventions.


National Network of Oral Health Access (NNOHA)

Through the collection and sharing of promising practices,  NNOHA promotes greater integration between safety-net providers and health care centers to reduce disparities and improve oral health among vulnerable populations.

Recommendation 4B: Integrate into provider training mental health, social stressors, and trauma education relevant to infants and families.

There is increasing awareness that numerous factors can contribute to health and well-being other than physical maladies and individual behaviors. Often times, there is a story behind the physical presentation of illness, especially with populations at greatest risk such as low-income and minority populations. Mental health, social stressors and trauma are the pictures that tell that story. There is documented research that the aforementioned can significantly impact health and well-being, particularly when experienced as a child, the lasting effect can impact adult health. 59–61   This includes mental illness, stress and trauma experienced by mothers that can impact the health of their children or unborn baby. In Connecticut, more than 25,000 children per year experience some type of significant trauma, and 80% of children screened in juvenile detention report a history of trauma.62   According to a study done by the Mental Health Outreach for Moms (MOMS) Partnership, 67% of the 898 mothers screened in New Haven stated they needed help coping with traumatic events.63 75% of mothers reported needing help to manage feelings of sadness or depression, controlling stress, and coping with traumatic events.  Of the one third that stated they received care for any of the aforementioned, some found it difficult to get the help they needed.63


Integrating mental health, social stressors and trauma education relevant to infants and families into provider training will prepare providers to effectively treat patients presenting with a myriad of cofactors affecting their health. It provides a perspective that not only improves health, but truly works toward well-being which includes social, emotional and spiritual health. It will help to prepare providers that are trained in ameliorating these issues which will lead to healthier moms and ultimately healthier babies.

Recommendation 4B – Promising and emerging examples

The Institute for Health and Recovery (IHR) strives to incorporate an understanding of the significant impact of violence and trauma, especially on substance use and recovery, in the design and delivery of human services.  IHR’s Trauma Integration Specialists provide training and technical assistance to service providers on how to integrate knowledge of trauma, domestic violence, and sexual assault into the provision of local and national services. Specialists work with service providers to integrate an understanding of trauma into their existing programs and activities, addressing trauma for women, men, children and youth, and using evidence-based practices. IHR trains staff of Early Intervention, Head Start, and other early childhood programs on the impact of trauma on young children and of substance use on families. IHR staff also participates in interagency task forces and coalitions to promote trauma integration in human services.


Connecticut Health and Development Institute of Connecticut, Inc. (CHDI), Farmington, CT

CHDI has been working to institute a trauma-informed system of care in Connecticut for over 10 years.  They have done so by developing tools for providers such as a trauma screening tool for children, and by providing training for professionals on evidence-based trauma informed care models and tools.  They work with state and local partners and have made recommendations on how to continue implementing and sustain a trauma informed care environment.  This is an example of efforts that are already in place and working. Supporting and partnering with efforts like this can help the state and all its providers work toward trauma informed care for all residents, particularly those suffering from traumatic experiences that are often overlooked.60,62,63


Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse

This handbook presents information that will help health care practitioners practice in a manner that is sensitive to the needs of adult survivors of childhood sexual abuse and other types of interpersonal violence. It is intended for health care practitioners and students of all health disciplines who have no specialized training in mental health, psychiatry, or psychotherapy and have limited experience working with adult survivors of childhood sexual abuse.

Refer to Appendix C for additional Tier 4 strategies supported by Coalition members.

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