the role of home visiting in improving birth outcomes · mihp: meghea et al. pediatrics, 2015....

THE ROLE OF HOME

VISITING IN IMPROVING

BIRTH OUTCOMES

Kay A. Johnson

Presentation at the

National Summit on Home Visiting

November 16, 2016

4.63 4.54 4.66 4.62 4.52 4.54 4.46 4.42 4.29 4.18 4.05 4.06 4.01 4.04 3.94

2.28 2.31 2.31 2.23 2.27 2.34 2.24 2.33 2.322.22

2.10 2.01 1.97 1.93 1.88

0

1

2

3

4

5

6

7

8

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Rat

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Neonatal Postneonatal

6.91 6.85

6.076.39

6.15

6.75 6.856.61

6.97 6.79 6.87 6.69

Infant, Neonatal and Postneonatal Mortality Rates, US, 2000-2014.

Source: CDC/NCHS. National Vital Statistics System. All final data.

Johnson. Role of Home Visiting in Improving Birth Outcomes. National Summit on Home Visiting. 11/2016

5.98 5.965.82

Percentage of births that were preterm by maternal

race/ethnicity, US, 2000, 2005, 2011, and 2014

11.610.4

17.4

11.2

12.711.7

18.4

12.111.710.5

16.8

11.7

9.68.9

13.2

9.0

0

2

4

6

8

10

12

14

16

18

20

Total Non-Hispanic white Non-Hispanic black Hispanic

2000 2005 2011 2014


Source: CDC/NCHS. All final data. Note details not shown for American Indian/Alaskan

Native, Asian, and multiple race categories.

US HHS Secretary’s Advisory

Committee on Infant Mortality (SACIM):

A Framework for a National Strategy to

Reduce Infant Mortality


Download report at: http://www.hrsa.gov/advisorycommittees/mchbadvisory

/InfantMortality/About/natlstrategyrecommendations.pdf

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The SACIM recommendations acknowledge that reducing U.S.

infant mortality will require a multi-faceted effort, including practice

improvement by providers, changes in knowledge, attitudes and

behaviors of men and women of childbearing age, improved

coverage and access to care, empowered communities, health

equity, and a serious commitment to prevention by all.

In June, 2012, Health and Human Services

(HHS) Secretary Sebelius made a commitment

to the development of the nation’s first national

strategy to reduce infant mortality.

The SACIM report made recommendations to

serve as the framework for the HHS to define

and implement an official federal action plan.

Strategic Directions: 6 Big Ideas1. Improve the health of women.

2. Ensure access to a continuum of safe and high-

quality, patient-centered care.

3. Redeploy key evidence-based, highly effective

preventive interventions to a new generation.

4. Increase health equity and reduce disparities by

targeting social determinants of health through

investments in high-risk communities and initiatives to

address poverty.

5. Invest in adequate data, monitoring, and surveillance

systems to measure access, quality, and outcomes.

6. Maximize the potential of interagency, public-private, and

multi-disciplinary collaboration.


http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/About/natlstrategyrecommendations.pdf

http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/About/natlstrategyrecommendations.pdf

Preterm birth prevention

• Unequal treatment, health inequities, and risks yield disparities by race/ethnicity, and socioeconomic status on the incidence and severity of preterm birth (PTB).

• More research needed, but we know enough to act now.

• Consumer education tools and clinical interventions exist to effectively address a range of risk factors for PTB.

• Sample opportunities:• Knowledge and attitudes of women and health providers (IOM pp 288)

• Diagnosis and treatment of preterm labor (IOM pp 284-301)

• Progesterone(17P) as treatment for women with a prior singleton preterm birth who is pregnant with a singleton

• Smoking cessation

• Congenital syphillis & other infections under diagnosed and treated

• Psycho-social risks such as stress, discrimination, social support.


Issues related to prenatal period• Renewed attention to prenatal care period is essential.

• Although prenatal care access was improved, mixed results regarding whether the Medicaid prenatal care expansions led to improved birth outcomes.

• Medicaid expansions did too little to improve access and quality for highest risk women with complex, multiple health and social issues.

• Recent focus more on preconception and interconception.

• Increasing use of high quality prenatal care will require effort at the clinical, community, policy, and system levels.

• Improving the content and quality of prenatal care will require new and more robust interventions.


Source: Handler A & Johnson K. A Call to Revisit the Prenatal Period as a Focus for Action Within

the Reproductive and Perinatal Care Continuum. Matern Child Health J. 2016.

Using Home Visiting to Improve Birth

Outcomes in the United States


What do we know about the role of home

visiting in improving birth outcomes?• Few studies of home visiting have found significant impact on

birth outcomes.

• Some studies of home visiting have shown impact on prenatal care utilization.

• A small number of studies point to leverage points such as early prenatal engagement, retention, intense dosage, and focused interventions during the perinatal period.

• Potential for impact may be greatest for subsequent pregnancies, particularly interconception care and focus on birth spacing.

• What you learn depends on how you ask – research design

• Different conclusions among systematic reviews (e.g., Filene et al; Isselet al; Holland et al; Finello et al).


Summary of literature on infant mortality

Outcome Results Program:

Study

Infant

mortality

In case-control study, infants whose families did

not receive home visiting 2.5 times more likely to

die in infancy.

Every Child

Succeeds (ECS):

Donovan et al.

Pediatrics, 2007.

Infants with any family participation had lower

odds of infant death. Enrollment by end of 2nd

trimester, risk screening, and >3 visits reduced IM

odds further.

MIHP: Meghea et al.

Pediatrics, 2015.

Women visited by paraprofessionals had fewer

subsequent fetal deaths.

NFP: Olds et al.

Pediatrics, 2004.


Summary of literature on pregnancy spacing

Outcome Results Program: Study

Inter-

pregnancy

or inter-

birth

interval

Nurse visited women had longer intervals

between births of 1st and 2nd children.

NFP: Olds et al.

Pediatrics, 2007; Olds

et al. Pediatrics, 2004

(Denver); Olds et al,

Pediatrics, 2004

(Memphis); Olds et al.

Pediatrics, 2002;

Kitzman et al. JAMA,

2000; Olds et al. Am J

Public Health,1988;

Olds et al.

JAMA,1997.

Increased pregnancy spacing (>18 months)

observed among women with at least

moderate home visiting participation.

HFA/ECS: Goyal et al.

Pediatrics, 2013.

High attenders (with <50% recommended

visits) had fewer subsequent pregnancies than

did the full control group.

NFP: Holland et al.

Am J Public Health,

2014.


Summary of literature on preterm birth


Study

Preterm

birth

(PTB)

Enrollment by end of 2nd trimester, risk

screening, and >3 visits, reduced risk for PTB

and VPTB greater for black women.

MIHP: Roman et al.

JAMA Pediatr, 2014.

Among high-risk, first time mothers enrolled in

prenatal home visiting, higher dosage of HV

associated with reduced likelihood of PTB.

HFA/ECS: Goyal et

al. Pediatrics, 2013.

Four* of 15 studies showed a significant effect of

HV on gestational age / PTB. Additional 3

studies found a non-significant but positive effect

for HV.

Multiple programs:

Issel et al. JOGNN,

2011.


* In order of strength of study: Bryce et al. 1991; Sangalang et al. 2006; Carabin et al.

2005; and Heins et al. 1987.

Summary of literature on low birthweight


Study

Low

birthweight

(LBW)

Participants with enrollment by end of 2nd

trimester, risk screening, and >3 visits had lower

odds of LBW and VLBW.

MIHP: Roman et al.

JAMA Pediatr, 2014.

Significantly fewer LBW births among those

enrolled earlier < 30 weeks, at 24 weeks, and at

16 weeks.

HFA: Lee et al. Am J

Prev Med, 2009.

Women visited by paraprofessionals had fewer

LBW births.

NFP: Olds et al.

Pediatrics, 2004.

Positive effects on LBW and PTB only for <17

years and smokers.

NFP: Olds et al.

Pediatrics, 1986.

Seven* of 28 studies showed significant increase

in birth weight for women with prenatal HV,

including only 3 of the 12 RCTs.

Multiple programs:

Issel et al. JOGNN,

2011.


* In order by strength of study: Norbeck et al.1996; Lee et al. 2009; Sangalang et al. 2006;

Baldwin et al. 1998; Carabin et al. 2005; Brooten et al. 2001; and Keeton et al. 2004.

Summary of literature on prenatal careService Results Program:

Study

Prenatal

medical

care

(PNC)

Five* of 11 studies reporting found a significant

improvement in use of PNC for women with HV,

either more PNC visits or more adequate PNC

than comparison group.

Overall prenatal home visiting was associated

with increased prenatal care utilization in more

than one third of the total studies reviewed.

Multiple programs:

Issel et al. JOGNN,

2011.

Women in Medicaid HV program had higher odds

of receiving any PNC & adequate amount of PNC

(timing and number of visits).

MIHP: Meghea et

al. Am J Prev

Med, 2013.


* In order by strength of study: Hardy et al. 1987; Rogers et al. 1996; Bradley and Martin

1994; Heins et al. 1987; and Keeton et al. 2004.

Summary of literature on intervention doseService Results Model

Prenatal

home

visits

Enrolled by 26 weeks with ≥8 completed visits had

lower risk of PTB compared to those with ≤3 visits.


Pediatrics, 2013.

Only 7% enrolled early and received ≥75% of

expected prenatal home visits.


J Epidemiol Comm

Health, 2016.

High HV attenders: most visits & good outcomes.

Low attenders: most education & best outcomes.

Increasing attenders: fewest completed home

visits, poorest intake characteristics, and poorest

outcomes.

NFP: Holland et al. Am

J Public Health, 2014.

Enrollment by end of 2nd trimester, risk screening,

and >3 visits showed better outcomes.

MIHP: Roman et al.

JAMA Pediatr, 2014.

A dose–response effect showed greater benefit

conveyed to those families enrolling earlier in

pregnancy (and thus receiving >7 visits).

HFA: Lee et al. Am J

Prev Med, 2009.


Measuring Success and Opportunity in

Home Visiting


Three Types of Measurement

Aspect Quality Improvement Performance & Results

Accountability

Evaluation & Research

Purpose Improvement of services Assurance, trends,

accountability

New knowledge, evaluation

Bias Accept consistent, known

bias

Set measures to reduce

bias

Design to eliminate bias

Sample size “Just enough” data, small

sequential samples

Aim for 100% available,

relevant data

Adequate for design, plus

“just in case” data

Hypothesis Hypothesis flexible,

changes as learning

occurs

No tests, no hypotheses Fixed, generally

predetermined hypotheses

Testing Sequential tests, small

tests of change

No tests One or two larger overall

tests of hypotheses

Measuring

improvement

Run charts, Shewhart

control charts, etc.

General trends, no tests Statistical tests (e.g., t-test,

p-values, chi square)

Confidentiality

of data

Data used by those

involved with QI project

Data available for public

consumption and review

Research confidentiality

protections as needed

Adapted from IHI: Solberg, L I; Mosser, G; McDonald, S "The three faces of performance measurement: improvement,

accountability, and research." The Joint Commission Journal on Quality Improvement. 23, No. 3 1997, pp. 135-47.


What we know

What we do

Yesterday Today Tomorrow

• Breastfeeding

• Developmental screening

• Family engagement

• Maternal depression

• Postpartum visits (IC care)

• Smoking

• Well child visits

MIECHV Constructs goals

ADVANCING CQI IN HOME VISITING / 2

Using QI to Close the Know-to-Do Gap

GAP

Source: Institute for Healthcare Improvement, 2013

Home Visiting Collaborative Improvement

and Innovation Network (HV CoIIN)HV CoIIN teams from local HV agencies across 11 states, and one

non-profit, to seek collaborative learning, use rapid cycle testing,

share best practices, and build QI capacity.

2016 HV CoIIN topic areas and aims are:• Breastfeeding Aim: 30% of infants will be fed exclusively breastmilk at 3 months and 15% at

6 months.

• Developmental Promotion, Early Detection and Intervention Aim: 80% of children with developmental or behavioral concerns will receive

assessment and intervention in a timely manner.

• Maternal Depression Aim: 85% of women who screen positive for depression and access services

will report improvement in symptoms.

• Family Engagement Aim: 85% of enrolled families will receive 100% of expected home visits.

To learn more, visit http://hv-coiin.edc.org/

http://hv-coiin.edc.org/

Pew Home Visiting Campaign, Data for

Performance Initiative: Recommended Indicators

• Maternal depression screening/referral

• Postpartum visit

• Interbirth interval

• Maternal educational achievement

Maternal health and achievement

• Child development screening/referral

• Child development gains (data development agenda)

• Child maltreatment

• Well-child visits

• Maternal smoking or tobacco use

Child health, development and safety

• Breastfeeding

• Parental capacity (data development agenda)Parental skills and capacity

• Low birthweight or preterm birth (in select states)

Perinatal outcomes


I. Maternal and Newborn Health

II. Child Injuries, Maltreatment, and

Reduction of ED Visits

III. School Readiness and Achievement

IV. Crime or Domestic Violence

V. Family Economic Self-Sufficiency

VI. Coordination and Referrals

Benchmark AreasPreterm Birth; Breastfeeding; Depression Screening; Well-Child Visit; Postpartum Care; Tobacco Cessation Referrals

Performance Measures

Safe Sleep; Child Injury; Child Maltreatment

Parent-Child Interaction; Early Language and Literacy Activities; Developmental Screening; Behavioral Concerns

IPV Screening

Primary Caregiver Education; Continuity of Insurance Coverage; Insurance Coverage

Completed Depression Referrals; Completed Developmental Referrals; IPV Referrals

New Federal HV Performance Measures

Research and Evaluation• Each year, 3% of the MIECHV federal funding is set aside

research and evaluation activities, including:

• state and tribal grantee-led evaluations,

• MIHOPE national evaluation,

• Home Visiting Applied Research Collaborative, and

• Tribal Early Childhood Research Center.

• HOMVEE assesses quality of HV-related research

• Home Visiting Applied Research Collaborative (HARC

www.hvrn.org )

• Also model and program level research and evaluations


http://www.hvrn.org/

MIHOPE-Strong Start Evaluation (1)

Maternal and Infant Home Visiting Program

Evaluation (MIHOPE)-Strong Start

•Co-sponsored by CMS, ACF, HRSA

•Large study on effectiveness of HV on maternal and

infant health outcomes, focus on Medicaid.

•Studying effects of home visiting on Medicaid

recipients for HFA and NFP models

•Home visiting, vital statistics, and Medicaid data

from 20 states and > 40 agencies

Source: Lee et al. Cheaper, Faster, Better: Are State Administrative Data the Answer? The MIHOPE-

Strong Start Second Annual Report. OPRE Report 2016-09. OPRE/ACF/HHS January 2015.

MIHOPE-Strong Start Evaluation (2)

Key early findings align with larger issues.

•Using administrative data is a multi-faceted and

challenging process, often requiring legal agreements

or IRB approval for sharing data.

•Not all states are able or willing to provide Medicaid

and birth certificate data, fewer have linked data.

•Administrative data reporting often has time lags.

•Medicaid managed care reduces available data.

•Lack of national Medicaid data impedes measurement

Source: Lee et al. Cheaper, Faster, Better: Are State Administrative Data the Answer? The MIHOPE-

Strong Start Second Annual Report. OPRE Report 2016-09. OPRE/ACF/HHS January 2015.

Conclusions• HV population starts with higher risks.

• HV not getting retention and utilization patterns

desired, particularly prenatally.

• HV programs not all focused on improving birth

outcomes, or prenatal services.

• HV programs not all focused on women after

pregnancy (e.g., interconception, birth spacing).

• Small sample sizes and study designs make it

difficult to show impact on birth outcomes.

• Some studies show promise.

• We must not overpromise!


Programmatic research on birth outcomes:

Every Child SucceedsNeera Goyal, MD MSc

Assistant Professor of Pediatrics

Perinatal Institute

Cincinnati Children’s Hospital Medical Center

High-risk pregnancy and home visiting• Self-selecting population

• Participants are at higher risk for adverse outcomes

• Willingness to voluntarily participate in this voluntary program

• Higher clinical or psychosocial needs • Higher motivation level• Programmatic outreach and messaging• Availability of community-based resources

(i.e. how well is ‘the system’ working?)

Who is referred, who enrolls?

Study design

• Retrospective study, 2007-2009

• County-wide referral and enrollment in home visiting

• Linked vital statistics, home visiting, and census data

• First-time mothers meeting eligibility criteria (low income, unmarried, or < 18 years)

• Generalized linear modeling determined factors associated with relative risk of

• 1) referral to home visiting among eligible mothers, and • 2) enrollment after referral

• Ecologic framework• Maternal clinical and social factors

• Home visiting agency

• Community-level deprivation (Townsend index)• unemployment

• access to transportation

• home ownership

• household crowding



All births in Hamilton

County, Ohio 2007-2009(N=34,994)

First-time mothers

(N=13,723)

Eligible for home visiting

(N=8,187)

Referred to home visiting

(N=2,734 )

Enrolled in home visiting

(N=1,543 )

Never enrolled

(N=1,191)No referral tohome visiting

(N=5,453)Not eligible for

home visiting(N=5,536)

Non first-time mothers

(N=21,271)

Likelihood of referral

N= 8,187

Number of eligibility criteria

1 (reference)

2 1.87 (1.60, 2.18)

3 2.43 (2.07, 2.85)

Race

White (reference)

Black 1.42 (1.32, 1.53)

Maternal education

No high school degree (reference)

High school degree 0.80 (0.73, 0.88)

Any college 0.55 (0.49, 0.61)

Smoker 1.02 (0.94, 1.11)

Pregnancy complication 0.89 (0.84, 0.94)

Adjusted relative risks

Likelihood of referral

N= 8,187

Likelihood of enrollment

N=2,734

Number of eligibility criteria

1 (reference) (reference)

2 1.87 (1.60, 2.18) 1.05 (0.94, 1.17)

3 2.43 (2.07, 2.85) 1.13 (0.98, 1.30)

Race

White (reference) (reference)

Black 1.42 (1.32, 1.53) 1.02 (0.93, 1.11)

Maternal education

No high school degree (reference) (reference)

High school degree 0.80 (0.73, 0.88) 1.10 (1.00, 1.21)

Any college 0.55 (0.49, 0.61) 1.17 (1.07, 1.28)

Smoker 1.02 (0.94, 1.11) 1.00 (0.92, 1.08)

Pregnancy complication 0.89 (0.84, 0.94) 1.61 (1.51, 1.71)

Adjusted relative risks

• Referrals appropriately targeting the highest risk, eligible population

• Young age/lower education less likely to enroll

• Prenatal referrals more likely to enroll

• Those with complicated pregnancy more likely to enroll

• More connected to health care system?

• Greater perceived vulnerability?

• Higher support needs?


Home visiting and early prenatal enrollment

Diabetes mellitus

Hypertension

Smoking

Substance use

Poor nutrition

Intimate partner violence

Infection

Stress and depressionPrevious

preterm birth

Home visiting and early prenatal enrollment

• Most enroll in home visiting late in pregnancy

• Most receive relatively few home visits

• Limited opportunity to address modifiable risks

• May impact programmatic evaluation

Prenatal home visiting engagement

Study design• Retrospective, cohort study

• First-time mothers enrolled prenatally in home visiting, 2007-2010

• Primary outcome: early prenatal enrollment• First home visit by 20 weeks gestation

• Enrollment by 20 weeks AND receipt of ≥ 75% expected prenatal home visits

• Multi-level, multivariable regression analysis

Prenatal home visiting engagement

N=837

25.3% enrolled by 20 weeks gestation

7.4% with expected visit

frequency

Maternal ageEducation level

Hypertensive disordersAgency variation

Community effects

Local programmatic findings

• Infant mortality

• Preterm birth and birthweight

• Subsequent pregnancy spacing

• Subsequent preterm birth

Infant mortality and home visiting

Study design

• Retrospective, case-control design

• Participants matched by gestational age, prior pregnancy loss, marital status, maternal age

• Multivariable logistic regression, adjusted for• prenatal care, smoking, education, race, age

• 4,995 non-participants and 1,665 home visiting enrollees

Results of infant death study

Race-specific, adjusted risk of death

Preterm birth and home visiting

Study Design• Retrospective cohort study

• First time mothers with singleton pregnancies

• Enrolled prenatally

• Linked to birth data in Ohio, 2007-2010

• To evaluate dosage effect of prenatal home visits • Hypothesis: Adjusting for other risk factors, higher

number of prenatal home visits in the first and second trimester would be associated with a reduced likelihood of adverse pregnancy outcomes

Measures: PTB & SGA• Outcomes

• Preterm birth (PTB), defined as birth prior to 37 weeks• Small for gestational age (SGA), based on categorized

birth weight using validated growth curves

• Key Predictors• Gestational age at enrollment • Number of completed prenatal home visits prior to 26

weeks (for PTB analysis) • Used 26 week cutoff because preterm birth is time dependent• Duration of enrollment, number home visits also time

dependent

• Total number of completed prenatal home visits (for SGA analysis)

Results

Preterm birth 10.9%

SGA status 17.9%

Mean GA at enrollment:

18 weeks

Home visits by 26 weeks:

ranged 1-16 visits

Adjusted odds ratio, preterm birth – all it early preterm

Adjusted hazard ratio, SGA

Study conclusions• Significant reduction in likelihood of adverse

outcomes associated with receiving high number of prenatal home visits

• Early intervention at a high intensity may be necessary to

• address modifiable risk factors

• achieve measurable benefits of this intervention

Spacing and repeat preterm birth

Study Design

• Retrospective, longitudinal cohort study

• High-risk, first time mothers in Hamilton County, Ohio from 2007-2009

• Home visiting data linked to Ohio vital statistics for index pregnancy

• Linkage to subsequent births in Ohio through 2012

• Everyone censored to a 3-year time frame

Key outcomes

• Inter-pregnancy interval: time from index birth to conception of the next pregnancy

• Also analyzed very short intervals (≤ 6 months)

• Also evaluated subsequent preterm birth risk

Two-phased analysis

Phase 1: Matched 1:1 control cohort of non-enrolled mothers

• Logit propensity score for likelihood of enrollment

• Other matching variables: race, age, year of birth, zip code

Phase 2: Within cohort comparison, by level of participation• Low (0-25% of expected visits)

Medium (25-75%)High (75-100%)Very high (>100%)

Results

1,543 home visiting participants

37% low participation 50% medium participation

10% high participation 3% very high participation

1,460 matched participants 1,460 matched controls

PHASE 1 ANALYSISn=2,920

Results

1,543 home visiting participants

37% low participation 50% medium participation

10% high participation 3% very high participation

1,460 matched participants 1,460 matched controls



17% with IPI < 18 months5% rapid repeat pregnancy

12.3% subsequent preterm birth

Cumulative hazard function, repeat pregnancy within 18 months

Subsequent preterm birth, adjusted odds ratio (Phase 2)

Study conclusions• Effects of home visiting on pregnancy

planning indicate dosage response to a degree

• Programmatic impact may be influenced by attrition (as well as program content)

• Rapid repeat pregnancy a significant risk factor for preterm birth among home visiting participants

• Pregnancy spacing an important target to achieve long term benefits

Limitations

• Errors of administrative data

• Potential selection bias due to unmeasuredconfounding

• Potential ascertainment bias (i.e. only using Ohio birth data)

• Generalizability due to regional study population

Takeaway• Pressure to demonstrate success with birth

outcomes.

• Timing, dosage, and exposure matter for improving birth outcomes with home visiting.

• These questions are central to determining impact.

• Seem like straightforward questions, but they’re not.

• Findings suggest home visiting may have an impact, however

• Unanswered questions remain • Real world application introduces several challenges

• More research, performance monitoring, and QI are needed.

Every Child Succeeds

• Created in July 1999; three founding partners:• Cinti. Children’s Hospital Medical Center (serves as managing partner)

• United Way of Greater Cincinnati

• Cinti-Ham’l Co. Community Action Agency/Head Start

• Mix of public/private funding provides stability• United Way of Greater Cincinnati

• Kentucky HANDS

• Ohio Help Me Grow

Every Child Succeeds: Home Visiting

• All parents want the best for their children

• Inspired by brain research, importance of first 1,000 days

• First time mothers with demographic risks, enrolled prenatally through 3 months

• Ohio & Kentucky, 7 counties

• 3 national models: Healthy Families America® , HANDS, EHS, P-3 years

• Since 1999: 24,000 families and 550,000 home visits

67

Prevention focus• Increase healthy births• Optimize child development• Promote attachment• Create nurturing home

environments• Connect with healthcare

providers• Develop life goals• Encourage healthy

relationships• Foster social support

Every Child Succeeds: Prenatal Focus

• Access to health care• Connection to other resources• Psychosocial support• Comprehensive curriculum

• Prenatal care/concerns• Nutrition• Breastfeeding• Smoking• Fetal development• Oral health• Stress reduction• Depression screening• Health checklist• Pregnancy spacing

2016 Report Card:• 70% of moms enrolled prenatally • 6,000 prenatal home visits

68

Prenatal Performance Metrics

Healthy Deliveries

Target 2015 Q1 Q2 Q3 2016Gestational Age >37 Weeks

90% 91% 92% 90% 95% 92%Birth Weight > 5.5 lbs.

90% 90% 92% 91% 94% 92%Depression Screening- Prenatal

90% 86% 87% 88% 88% 88%Depression Screening- Postpartum

90% 83% 86% 87% 64% 79%Moving Beyond Depression Referral

35% 34% 40% 45% 32% 39%Postpartum Visit Attendance

85% 63% 74% 68% 69% 71%

Trend quarterly performance

Start Strong Community Collaborative• Focus on two urban neighborhoods

• Outcomes/aims: reduce preterm births, lower ED visits and cut healthcare costs

• Goals:• Better identify (earlier) and screen pregnant women at high risk

for delivering prematurely

• Bring together previously unconnected clinical care (OB providers), home visiting, and social services to surround moms with the services they need

• Create a community-based support network to encourage healthy behaviors that may lower the risk of preterm birth

Maternal Risk of Moms in Avondale

•98% Low income

•98% Unmarried

•35% Late or no prenatal care

•91% African American

Additional Risk Factors

• 45.7 percent have four or more ACES

• 6.9 percent smoke during pregnancy

• 5.8 percent had a prior preterm birth

• 20.5 percent elevated score for depression

SMART Aim

Key Drivers

Interventions (LOR #)

Increase the % of

ECS referrals* that

have a first home

visit within 10

business days

* In zip codes: 45204,

45205, 45229

Consistent, accurate, and

family-centered program

presentation to eligible clients

Effective coordination of care

with other resources and

programs

Increased maternal awareness

and perception of program

value

Standard (best) practices to

engage clients in program

Timely and actionable data

shared regularly

Care Connections• ECS II – GSH Case Conferencing (3/15, 10/15); ECS I BA added 10/15; Add Santa Maria 1/16; ADAPTED in-person case

conference 2/16; ABANDONED 2/16

• Track communication to understand collaboration w/o case conference(3-4/16)

• Community outreach events – Staff attending, promoting to families (9/15)

• ECS I – BA and SM – OB Care Team Consent (10/15) ADOPTED

• Referral Source Status Report (10/15) ADOPTED 3/16, PPC MH Report (10/15)

• Test modified case conference with PPC (3-4/16)

• Peds Care team consent report (3/16)

Referral Processing• Central staff priority identification, huddle discussion on outreach (8/15-9/15) ADOPTED 10/15

• Referral Source Status Report (10/15) ADOPTED 3/16; ADAPTED Refined Report (8/16)

Complete and up-to-date

contact information for client

ECS SS CCLC Engagement Improvement ProjectKey Driver Diagram (KDD)

Project Leader(s): Margaret Clark, ECS Central Staff

Revision Date: 10/1/15 v2

Eliminate all infant

deaths in Hamilton

County* 96 infant deaths in 2014

Global Aim

Program Awareness• Referral source outreach and introduction to ECS programs

• Meetings with GSH and UCMC/CHD partners (9/15)

• Meeting with PPC to discuss enhanced relationship for Team A and Team B (9/15)

• Community Liaison-generated referrals (5/16- present); ADAPTED with Logo wear (7/16)

Monitoring• Timely, frequent and complete effort and tracking documentation

• ECS I and ECS II Case Review (1/15)

• Referral conversion by referral source report (9/15)

• Days between referral and 1st visit report, % ≤ 10 days

• Engagement by MOB age, GA, and community reports

• Weekly touch base/check-in meetings for CCLC teams (8/15-9/15)

Value overview• ECS II – Survey of referrals that decline program (9/15) POSTPONED 10/15

Outreach • BA Direct assignment to agency (2/15-3/15)

• ECS II Mom-to-mom referrals (8/15) POSTPONED 10/15

• SM 04/05 staff designation (8/15-9/15) ADAPTED 10/15

• ECS I – BA and SM assessment priority (8/15)

• Central Community Staff increase contact to families for upcoming parent group – mailers, text messages, phone calls

(8/15)

• BA Parent group connections (8/15)

• ECS II – Supervisor outreach calls (8/15) ABANDONED

• GSH FMC - Coordinate calls w BA, SM, Central Staff while mom in office (2/16)

• Texting moms upon receipt of referral (5/16), Adapted to re-engage moms (6/16); Texting new referrals (8/16)

• SM 0405 Assessment same or next day scheduling (7/16)

Community and healthcare

provider partnerships to

identify eligible clients

PDSA’s In Process (As of August 2016)

• Community Liaison Referral Testing (ECS Avondale)• Continued outreach in community to generate referrals, new sources of referrals,

and stronger connections with providers and programs.

• Referral Progress Report (ECS Avondale and Price Hill)• ECS Referral Feedback report is sent out to first round participants. Referral

sources receive information to track engagement of referrals in ECS. If client has not engaged, ECS and OB can work together to present program, identify sources to contact and coordinate outreach.

• Texting New Referrals (ECS Avondale and Price Hill)• Encourage quicker turnaround time and assignment to agency for first home

visit.

33%

100%

64%

54%

80%

50%

45%

100%

43%

33%

100%

17%

60%67%

40%

0%

29%

0%

17%11%

0%

21%

8%

40%

8%

18% 20%

0%

11%

0% 0% 0% 0%

20%

0% 0% 0%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan

15

= 9

Feb

15

n=3

Mar

15

n=1

4

Ap

r 1

5 n

=13

May

15

n=5

Jun

15

n=1

2

Jul 1

5 n

=11

Au

g 1

5 n

=5

Sep

t 1

5 n

=7

Oct

15

n=9

No

v 1

5 n

=5

Dec

15

n=

6

Jan

16

n=5

Feb

16

n=3

Mar

16

n=5

Ap

r 1

6 n

=1

May

16

n=7

Jun

16

n=3

Jul 1

6 n

=6

% R

ef w

ith

vis

it

Month of Referral

Percentage of Prenatal Referrals with First Visit (45229 Avondale)

% with 1st visit % 1st Visit <=10 days Target 50%

58% 60% 60% 61% 61% 61% 61% 60% 61% 61%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan 16n=178

Feb 16n=180

Mar 16n=182

Apr 16n=186

May 16n=187

Jun 16n=192

Jul 16n=193

Aug 16n=194

Sept 16 n=196

Oct 16n=196

Nov 16 n= Dec 16 n=

1st Visit by <=18 Weeks GAAvondale (45229)

Rate Target (75%)

14

51

38

2529

34

13

55

2428

59

21

43

29

13

70

61

21

12

01020304050607080

Jan

15

n=3

Feb

15

n=3

Mar

15

n=9

Ap

r 1

5 n

=7

May

15

n=4

Jun

15

n=6

Jul 1

5 n

=5

Au

g 1

5 n

=5

Sep

t 2

015

n=3

Oct

20

15 n

=3

No

v 2

01

5 n

=5

Dec

20

15

n=1

Jan

15

n=3

Feb

16

n=2

Mar

16

n=2

Ap

r 1

6 n

=0

May

16

n=3

Jun

16

n=1

Jul 1

6 n

=3

Au

g 1

6 n

=1

Sep

t 1

6 n

=0

Oct

16

n=

Day

s

Month of Referral

Time Between Referral and 1st Visit (ECS 1 and ECS II 45229 Avondale)

Avg Days b/w Ref and 1st visit Target =10 days

Desired Direction:

Cradle Cincinnati Learning Collaborative

• Partnership emanating from Start Strong

• Aim: to reduce Infant Mortality Rate (IMR) in Hamilton County from 9.5 to the national rate of 5.98 by December 2020

• Ensure more reliable delivery of evidence-based obstetric intervention (smoking, sleep position and spacing) and rapid access to early prenatal care, home-based services and postpartum care

• Measure for home visitation: first home visit within 10 days of referral

Blue line = CCLC Community Teams

Referrals with 1st Visit in <=10 Days

Dark line= ECS Referrals in 45229 with 1st visit in

<=10 Days

Conclusions• QI has value

• Aiming to fix problems identified in research• Pinpointing process problems and variations • Identifying KNOW:DO gap

• Training and curriculum changes can help

• Community system changes may be needed to improve referral process

• Some dilemmas inherent in prenatal period• Pregnancy confirmation, denial, delays in medical care• Too little too late to fix certain problems (e.g., preconception interventions

most effective in terms of folic acid or excess alcohol usage)

• ECS has built a data system, community engagement, partnerships, and delivery of various home visiting models that permit more intensive research, QI, and other efforts.

the role of home visiting in improving birth outcomes · mihp: meghea et al. pediatrics, 2015....

Documents