Colleen Kraft, M.D., FAAP Medical Director, Health Network by Cincinnati Children’s BUI UILDIN ING CAP APAC ACIT ITY Y AN AND SU SUPP PPORT RT FOR TWO GENE NERAT ATION ION PR PRIM IMARY ARY CAR ARE
Learning Objectives • Consider new models of primary care that prevent toxic stress and build the health of parents and children; • Recognize new financing models that promote two generation primary care; • Discuss ways maternal/child health professionals might advocate in translating science into healthier life- courses
Current Conceptual Framework Guiding Early Childhood Policy and Practice Significant Adversity Healthy Developmental Trajectory Impaired Health and Development Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments
The True Nature of Preventive Medicine Death Early Death Disease & Disability Adoption of Health-Risk Behaviors ?? Social, Emotional, and Cognitive Impairment Adverse Childhood Experiences Birth Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status Slide modified from V. J. Felitti
Advances in Developmental Science Li Life-Cour Course se Sc Scie ience nce Epig pigene netics tics De Developm lopmental ental Ne Neuroscience oscience
Eco-Bio-Developmental Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions The Basic Science of Pediatrics Life Course Science Eco cology ogy Becomes biology logy, And together they drive development lopment across the lifespan
Translation and Advocacy Epigenetics Physiology of Stress Neuroscience The Science cience of of Ea Early ly Brai ain n an and Child ild Development elopment Education Health Economics On One Science cience – Man any Im Implications plications The critical challenge now is to tr tran anslat slate game-changing advances in development opmental al sci cien ence ce into effective policies cies and pra ract ctices ices for families w/ children to improve educa cati tion on, health th and lifelong long pro roductiv ctivit ity
Critical Concept #1 PREVENTION OF ACES STARTS AT -9 MONTHS!
Impact of Early Stress MATERNAL STRESS TOXI XIC STRESS NEWBORN HPA methylation of the reactivity and salivary FETAL glucocorticoid cortisol levels (GC) receptor gene brain expression of the GC receptor
Carilion Clinic-Aetna Partnership Carilion Clinic ACO Carilion Private Clinic Practice Physicians Physicians 10
Virginia Medicaid Regions Update: 12/08/2011
Maternal-Child Triple Aim Optimize Health and Development Prevention of Adult Disease Reduce High Cost Care
Care Management Design • Home Visiting Contract • “High Touch”, in -person, in-home – Prenatal – Early Childhood – Asthma Case Management – Behavioral Health Case Management – Oral Health Screening/Dental Varnish
Home Visiting Intervention Pilot
Home Visiting = In-Home Prenatal Care Management IDEA AIM STATEMENT • Poverty is a risk factor for • Reduce the number of poor maternal and newborn infants born at <37 weeks outcomes. gestation and low birth weight (<2500 grams) by • What if every mother with 30% by December 2012 Medicaid had a Home utilizing home visitors as Visitor to provide support, in-home case managers. education, transportation? • How would this impact health of the next generation?
Driver Diagram Outcomes Primary Drivers Secondary Drivers Access to prenatal Reduced CONNECTION care numbers of Home Visitors connect premature and with pregnant moms; Health insurance low birth weight incentives; depression Team Huddles, CQI screening, referral , infants treatment Transportation Improved RELATIONSHIP maternal Access to behavioral Emotional support, health physical and healthy nutrition, behavioral smoking cessation, Emotional support health parenting readiness, pregnancy health and when to call Reduced cost of Healthy nutrition SYSTEMS care (due to Screening and reduced NICU Smoking Cessation enrollment for health insurance, In home days) data collection
National Benchmark=March of Dimes Virginia Roanoke/Allegheny • “C” grade for premature • Metrics worse for this birth region • Total prematurity = 11.3% • Prematurity = 12.2% • Late preterm (34-36 wk) • Late preterm (34-36 wk) = 8% = 10.1% • Uninsured = 17.2% • Uninsured =15.6% • Maternal smoking = • Maternal smoking = 15.2% 24.4%
Measures Health Care Cost Measure O Percent of infants born at > 37 weeks gestation O Percent of infants born between 34 and 36 weeks gestation (late preterm) O Birth weight Percent of infants <2500 grams O Percent of Pregnant Moms participants who smoke that stopped smoking P Percent of Pregnant Moms participants who start prenatal care in the first trimester P Percent of Pregnant Moms participants who attend all the recommended prenatal visits Percent of Pregnant Moms participants who are uninsured P Percent of Pregnant Moms participants identified with depression P P Percent of Pregnant Moms participants connected to treatment for depression C Cost of Care
1 st Trimester — Goal =90% Percent Goal = 90%
All Visits-Goal = 60% Percent Goal = 60%
Reduce Maternal Smoking by 1/3 Percent Goal = 16%
Perinatal Depression
Reduce Percentage of Infants born <37 weeks by 30% <37wk 34-36 wk Goal
Reduce Percentage of Term Infants born < 2500g by 30%
Cost of Care Note: One premature infant March 19-May 10
Theory on Preventing Prematurity The Challenge Seek Population Health Through Place Based Care Design for Sustained, Empathic Care Build Seamless Community Connections
Community Housing, partner violence, legal assistance, food assistance, mental health svcs UCMC University PPC Prenatal2 Hospital Pediatrics2 Prenatal3 ER Good Samaritan Pediatrics3 Good Samaritan Prenatal5 Hospital Prenatal6 Home visiting, Community health workers
Community Housing, partner violence, legal assistance, food assistance, mental health svcs Timely valued services that reduce hardships UCMC University Early, sustained, PPC Prenatal2 Hospital valued, evidence based prenatal Pediatrics2 Prenatal3 ER care for every mom Good Samaritan Pediatrics3 Good Early, valued, Samaritan Prenatal5 expert, accessible Hospital medical home for Prenatal6 every child Early, valued, accessible, coordinated care in the community Home visiting, Community health workers Activated mothers supported by engaged communities
Community Housing, partner violence, legal assistance, food assistance, mental health svcs Timely valued services that reduce hardships 90% by 15 weeks UCMC University Early, sustained, PPC Prenatal2 90% by 12 weeks Hospital 80% by 7 days 30% reduction valued, evidence based care for Pediatrics2 Prenatal3 E every mom 85% after ≥weeks Good Samaritan Pediatrics3 R Good Early, valued, Samaritan Prenatal5 expert, accessible Hospital medical home for Prenatal6 every child 90% by 15 weeks Early, valued, accessible, coordinated care in the community Home visiting, Community health workers 90% by 18 weeks Activated mothers supported by engaged communities
Community Housing, partner violence, legal assistance, food assistance, mental health svcs Timely: personal intake relationships; contingency planning Timely valued services that reduce Valued: referrer has deep knowledge of hardships service available 90% by 15 weeks UCMC Early: SDA, community fora, MOUs Sustained: call backs, scheduling University Valued : comm aware, feast, family Early, sustained, PPC Prenatal2 centered, what matters to me, 90% by 12 weeks Hospital 80% by 7 days 30% reduction valued, evidence empathy training Early: outreach, Evidence: OB bundle based care for Pediatrics2 Prenatal3 rescheduling, E Every: zip code, registry every mom Valued: comm knowledge, 85% after ≥weeks Good Samaritan Pediatrics3 Expert: anticipatory advice R Good Accessible: walk in appts Early, valued, Samaritan Prenatal5 expert, accessible Hospital medical home for Prenatal6 every child Early: phone referrals, lean 90% by 15 weeks processing Accessible: Early, valued, accessible, coordinated care in the Coordinated: 2 way consent, community huddles Home visiting, Community health workers 90% by 18 weeks Activated mothers supported by engaged communities Activated: contingency planning, what matters to me Engaged: video, educational fora, messaging, MOU’s, mentors
Critical Concept #2 SCREENING FOR TOXIC STRESS BELONGS IN THE MEDICAL HOME
Primary Care Innovation to Address Toxic Stress • Comprehensive approach to screening for hardships • Community system of partnerships • Home Visiting integrated with the Medical Home
DRAFT What A Well-Trained Potential Maslow’s Hierarchy of Needs Clinic Will Detect Collaborations Unemployment; lack Achieving of high school degree; potential ex-offender reentry issues Esteem & Overwhelmed new Respect parents; lack of parenting role models Belonging Domestic violence; mental health issues; inadequate education services Safety Hunger; homelessness; denial or delay of benefits; utility shut offs Basic Human Needs A. Henize (2013)
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