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PCC Highest Areas of Patient Population

Addressing Disparities in Perinatal Health Using a Collaborative Approach: The PCC Community Wellness Center’s Experience May 17, 2006 Mark Loafman, M.D., M.P.H. Andrea McGlynn, C.N.M., M.S.N. Chicago, IL. PCC Highest Areas of Patient Population.

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PCC Highest Areas of Patient Population

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  1. Addressing Disparities in Perinatal Health Using a Collaborative Approach: The PCC Community Wellness Center’s Experience May 17, 2006 Mark Loafman, M.D., M.P.H. Andrea McGlynn, C.N.M., M.S.N. Chicago, IL

  2. PCC Highest Areas of Patient Population

  3. Austin Community Selected Demographic/Health Data* Percent of Population • Chicago Department of Public Health – Chicago Health and Health Systems Project April 2006 • 2000 Census Data

  4. Austin vs. Chicago Selected Perinatal Indicators 2003 Austin vs. Chicago Infant Mortality 2003 Rate/1000 Live Births Percentage Source: Chicago Department of Public Health – Chicago Health and Health Systems Project April 2006

  5. Overview of PCC • History and mission • Full-service community health center since 1993 • 330 funding (FQHC) since 2002 • Model of care • Family Medicine • 9 of 18 Attendings with MCH/OB Fellowship • Peds, OB/GYN, CNMs, FNPs, LCSWs, Psych • Health education and outreach • Hosts MCH Fellowship and FM Residents • Experience with health disparities collaboratives

  6. PCC UDS Data

  7. HealthSystem Health Care Organization Community Resources and Policies Self-management support Delivery system design Clinical information systems Decision support Informed, activated Patient Prepared, proactive practice team Productive Interactions Functional and Clinical Outcomes Source: Institute for Healthcare Improvement Care Model

  8. Impact Analysis of PCC’s Model CLINICAL MODEL Community Problem Outcome FAMILY PRACTICE MODEL WITH OBSTETRICS Low birthweight (140/1,000 live births)* Very low birthweight (39/1,000 live births)* Low birthweight (101/1,000 live births)** Very low birthweight (9/1,000 live births)** Family Practice Residency MCH Fellowship Case Management Community Nursing AmeriCorps Outreach Workers * Austin area, 1999. Source: I-PLAN data system ** RSWH deliveries of PCC and unattached patients, 6-11/2004 Source: Perinatal database.

  9. Perinatal Pilot Collaborative Seeing wider opportunities to respond to the problem Environment Social & legal resources Genetic/familial life course Access to ongoing health care Maternal preconception health Opportunities to positively influence MCH PCC and Partners Influences on MCH Lifestyle/stressors/ stress response Psychological & spiritual support services Educational & economic opportunities SES conditions & disparities Environmental safety Early and individualized risk assessment and care Concurrent & prospective care management Networks & collaborations Prenatal course

  10. Example: Ramp-up of PDSAs Plan-Do-Study-Act Method of Making Changes • Identify opportunity, then champion the idea • PDSA changes (> 119 PDSAs in Perinatal Pilot at PCC) Outreach to patients Refined tracking form (follow-up needed) Patient given specific contact person for appt. (barriers to appointment) Algorithm to prompt care/red folders (more comprehensive approach) GDM screening at hospital OB triage

  11. At the Health Center Front-loaded care Prenatal sessions for all FP providers Psychosocial and depression screening (PHQ) Self-management goals Performance Improvement assistant (PIA) role At the Hospital “Red folders” algorithm/outreach to unattached patients Joint practice committee: pre-M&M quality assurance Top 7 Changes

  12. Process (as of 4/06)* HIV test (100%) Psychosocial risk assessment (83%) Prenatal depression screening (78%) SMG (50%) Early GDM screening (80%) Outcome (7/05 to 3/06)* Preterm labor (13%) Low birthweight (13%) Infant mortality (0) Perinatal PECS Data at PCCJuly 2005 to Present CHALLENGES * at pilot site only – selected indicators

  13. PatientSatisfaction Employee/ Provider Satisfaction Finance Team/Task Force P.I. Clinical & Collaboratives Grants Support Services Performance Improvement Program Identified Needs

  14. Communication and Systems Development Excerpt from PCC’s Perinatal Collaborative Aim Statement: “…implementation of a patient safety system that prepares the multidisciplinary PCC and WSMC teams for high-risk patient care (antepartum, intrapartum, and postpartum) and encourages self-reporting and identification of ‘near misses’ by November 2005 at PCC and WSMC Family Birthplace.” How do you measure that? Existence of… • Processes developed and “institutionalized” • Extend care management model into hospital • Evidence-based practice tools – algorithms, protocols, drills

  15. PCC Community Wellness Center/West Suburban Medical Center Integrative service delivery initiative Integrative medical education PCC Community Wellness Center Board of Directors CEO and President Chief Medical Officer WSMC Family practice residency WSMC (PHO) managed care South OP Site WSMC Site Erie Ct Site FellowshipTraining Lake Site Austin Site Salud Site • Target Population Reach by Risk Reduction Outreach • Yellow Brick Road (Women’s Sober Living • Haymarket House (alcohol/substance abuse • Infant Jesus Dental • UIC Dental School • Chicago Urban Ministries (counseling, housing) • Bethel New Life (social services, housing) • Formal Community • Collaborations • Circle Family Care • Interfaith House • Westside Health Authority • West Side Health Collaborative Care Coalition Integrative referral system WSMC Inpatient/outpatient diagnostics

  16. Closing the Gap Programs in Chicago Health Resources and Services Administration (HRSA) Closing the Health Gap Initiative on Infant Mortality Maternal and Child Health Bureau (MCHB) Risk Reduction Pilot Bureau of Primary Health Care (BPHC) Perinatal and Patient Safety Pilot Health Disparities Collaborative State MCH agencies and other grantees Perinatal collaborative pilot sites, then all FQHCs Target population reached by risk reduction outreach Target Population that accesses prenatal care

  17. Still More Needed to Close the Gap Health Resources and Services Administration (HRSA) Closing the Health Gap Initiative on Infant Mortality Maternal and Child Health Bureau (MCHB) Risk Reduction Pilot Bureau of Primary Health Care (BPHC) Perinatal and Patient Safety Pilot Health Disparities Collaborative State MCH Agencies and Other Grantees FQHCs (perinatal collaborative pilot sites then all FQHCs State MCH Agencies and Other Grantees Target Population that accesses prenatal care Unreached target population high-risk for infant mortality, only accesses emergency services …and address social, economic, environmental disparities

  18. PCC’s Plans for Collaborative Spread • To other PCC sites • Unattached population • Assist in spread to other FQHCs nationally

  19. Research to Better Understand: Role of prenatal care in improving outcomes Improved psychosocial screening and health Workforce development Model replication Integration of Services WIC/Case management together with CHC services Behavioral health Community-based agencies More Plans

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