NC BLP and FV HS mtg

Slide1: 

Healthy Start Model Components: Useful Tools for Community Problem Solving Evaluation Team: Healthy Start Annual Grantee Meeting August 6, 2007 NC Baby Love Plus Program Addresses Problems of Family Violence

Overview: 

Overview How NC used a Systems Approach to address community need Our local HS project was a great resource What Healthy Start Models we employed What was our strategy of ID and addressing problem Program features to address FV in the perinatal period Results Lessons learned

NC Healthy Start Baby Love Plus Covering 14 Counties w/ High IMRs : 

NC Healthy Start Baby Love Plus Covering 14 Counties w/ High IMRs Five County, Rural Area (green on map) Poverty, Unemployment, Isolation Limited Health Care options (mainly public clinics) IMR over 16 per 1,000 for Minorities; (> 3 x White rate) High Medicaid (70-80% of deliveries) High Prevalence Co-Morbidities: diabetes, obesity, hypertension

Slide4: 

1. Strengthen community networks and increase local ownership of problem BLP Community Consortium Family Development Retreats, Training Institutes Local Health System Action Plans 2. Identify families at risk of having problem pregnancies Outreach by Community Health Advocates (CHAs) 3. Link at-risk families with services through case management Maternity Care Coordination (MCC) Post-partum / Interconceptional Care Coordination 4. Improve existing clinical services Cultural sensitivity trainings In-services, Lunch-N-Learns Customer Service Trainings 5. Lower risks for and reduce disparities in infant morbidity and mortality Preconceptional health Pregnancy intendedness Short birth intervals Preterm deliveries Low birth weight births Neonatal, post-neonatal, and total infant mortality BLP Program Goals and Program Focus

Slide5: 

Indigenous outreach workers (n=8) to increase penetration within the community Agency-based outreach at WIC, family planning, DSS “In-reach” for appointments and follow-up / tracking / and support Health Education and Training Provide one on one education to all program participants in BLP in core areas Expand provider education on interconceptional care and perinatal depression Community education on perinatal risk factors and promotion of healthy pregnancies Outreach Northeastern BLP Program Models Case Management Comprehensive case management, emphasis on continuity of care and risk reduction Transportation to PNC, FP, and WCC visits Those enrolled in maternity care coordination (NC MPW: Baby Love) Services based on “risk level” extended to 24 months post-partum Increasing inter-partum spacing, particularly for women who have had LBW babies ALL pregnant/postpartum women screened for depression BLP Regional Consortium Five county area, since 1999 Planning Grant Consumers, providers, and community leaders (52 members) Local Health System Action Plan and County Action Committee

NC Healthy Start Baby Love PlusBuilding on NC Baby Love (Medicaid for Pregnant Women) Program: 

NC Healthy Start Baby Love Plus Building on NC Baby Love (Medicaid for Pregnant Women) Program Outreach Workers (Community Health Avdocates) Case Finders NC Baby Love Program Maternity Care Coordination Medicaid for Pregnant Women Maternity Outreach Workers WIC Prenatal Care Post-Partum Care Well-Baby Care Family Planning Family Care Coordination Child Service Coordinators

Acknowledging a Community Problem: 

Acknowledging a Community Problem What Northeastern NC BLP Regional data told us: High Unintended Pregnancy Rates (65.2%) High Unplanned Pregnancy Rates (80.4%) High levels of stress and stress-related factors: Job loss, self or partner: 33% Couldn’t pay bills: 25% Partner did not want pregnancy: 24% Argued w/ partner more than usual: 46% Recently had to move or homeless: 31%

Acknowledging a Community Problem: 

Acknowledging a Community Problem What FV-related data told us: Physical violence 2-4 x more likely for women w/unintended pregnancy (Gazamarian, JA, MCH Journal 4(2): 80, 2000) One in 4 women experience sexual violence in their lifetime (National VAW Survey, 2000) Abuse often begins and/or escalates during pregnancy (NVAW Survey, 2000) Almost all women who have live birth receive some PNC (Ventura et al, NCHS, 1998) Usual maternity client seen for average of 12-13 visits Many opportunities to address issue, establish relationship But <50% providers screen for FV (Parsons, et al MCH Journal 4(2), 2000) Overlap with IM disparity reduction risk factors Late or no prenatal care Unintendedness Substance abuse Depression, stress Poor weight gain Anemia Infections Pregnancy complications

Overlap: FV Population-at-risk and BLP Participants : 

Overlap: FV Population-at-risk and BLP Participants The typical woman reporting abuse is: In her childbearing years African American Equally likely to have completed high school or not Not employed Not married Currently in an intimate relationship Mother of one or two children The typical woman participating in BLP is: In her childbearing years African American Currently in an intimate relationship At high risk of poor birth outcome

Consortium’s County Action Committee Developing the LHSAP: 

Consortium’s County Action Committee Developing the LHSAP What are the types of factors and issues we must address if we are going to succeed in reducing disparities? Pre-pregnancy diabetes and hypertension Poor nutritional status and obesity Pregnancies within six months of delivery Extremely high rates of infections and untreated STDs Widespread substance abuse Exposure to environmental toxins What is missing? Lack of social support, depression, family instability Stress, job insecurity, poor housing unsafe neighborhoods

Local Health Systems Actions PlanAdopted December 2005: 

Local Health Systems Actions Plan Adopted December 2005 Two Focus Areas Supportive Housing: Security, and a Healthy Living Environment Coping Skills: Positive Interpersonal Relationships and Family Life Elements for Each Area Goal and Rationale Target Consumers and Target Partners Action Steps and Strategies Who Participates? Who is Responsible?

NC Baby Love Plus ProgramPost-Partum Case ManagementSix Program Areas and Sub-Domains: 

NC Baby Love Plus Program Post-Partum Case Management Six Program Areas and Sub-Domains

MCH Bureau SPRANS Grant: 2002 - 2005: 

MCH Bureau SPRANS Grant: 2002 - 2005 One of five grantees, NC only site that is rural Three-year, $150K per year One FT Social Work Specialist, PT Regional Manager, Mini-grants to local partner agencies (fatherhood, faith groups) Three Key Areas Strengthening Systems of Care Developing Screening Tools Establishing Referral Protocols and tracking Skill-building for PH and Soc Service providers Expanded provider network Identifying Families at Risk Treatment, Referral, Support for Families at Risk

Northeastern NC Baby Love Plus Strengthening Systems of Care to Address Family Violence: 

Northeastern NC Baby Love Plus Strengthening Systems of Care to Address Family Violence Family Violence Prevention Partners 5 Local Health Departments 3 Local FV Shelters & 3 Mental Health Programs Statewide Task Forces Private OB/Gyns

Program Activities—Early Steps: 

Program Activities—Early Steps Community Training Healthy Start Training Institutes Trainings during Consortium meetings BLP newsletter Domestic Violence 101—Male/Fatherhood partners Partner and Staff Trainings Procedural manuals Screening Recruitment of FV Social Work specialist

Slide16: 

Family Violence Technical Assistance March 29 – 30, 2004 9 a.m. – 4 p.m. Northampton County Health Department Jackson, NC There is no charge for this program. Lunch is provided. Day One: Effects of domestic violence on maternal & fetal/infant outcomes Developing community partnerships to address the needs of perinatal women who experience domestic violence around the time of pregnancy Strategies to integrate screening into existing practices Day Two: Networking, Leadership development

Program Activities—First Steps: 

Program Activities—First Steps Policy and Protocol Training Learn the procedure: Identify the abuse Assess risks and needs Provide referrals and assistance Document the abuse Follow-up Become familiar with resources: “Responding to Violence Against Women: A Guide for Local Health Departments,” NC DHHS, DPH, Injury and Violence Prevention Branch

Program Activities—First Steps: 

Program Activities—First Steps Create and share local protocols Meet with local partners Provide incentives to providers to increase community awareness

Program Activities--Screening: 

Program Activities--Screening Screening tools developed to elicit Recent and current experiences of abuse Types of abuse ● When? How often? ● How severe? Feelings Poor appetite ● Depressed Restless sleep ● Happy Lonely ● People unfriendly Enjoy life ● Could not “get going” Use of services Mental health, substance abuse, smoking cessation CPS, adoption, medical, DV, rape crisis Medical, legal, financial, housing, employment Religious

Slide20: 

Case Management Screening and Assessment MCC Clients Screened for FV each trimester Pregnancy Baseline Assessment Pregnancy Delivery/PP 3-month 6-month 12-month Post-Partum (six-week) Assessment Post-Partum (3-month) Assessment Post-Partum (six-month) Assessment Post-Partum (one year) Assessment Measurement Points

Program ActivitiesScreening, Assessment and Referral: 

Program Activities Screening, Assessment and Referral Screens done by Maternity Care Coordinator Have an-going relation with women in care Build trust to reveal abuse confidentially over time Assessments done by FV SW Specialist Transition seamlessly from assessment to treatment Referrals to specialized services when needed Referrals made by MCC or FV Specialist include Medical care, rape crisis, mental health services Housing, food, clothing Legal assistance, protective orders

Program Activities--CollaborationNetworking: 

Program Activities--Collaboration Networking Shelter representatives joined the Consortium Health Departments and three shelters developed MOU for procedures, protocols and interaction. Partnerships with UHURU and NC Fatherhood Connections Network

Program Activities--CollaborationExpanded Shelter Services: 

Program Activities--Collaboration Expanded Shelter Services Social Marketing via highway billboards Crisis-line telephone calls answered in person Distribution of cell phones with 911 capability Off-site support groups offer confidential site for information and counseling

Program Activities--CollaborationMale and Fatherhood Initiatives: 

Program Activities--Collaboration Male and Fatherhood Initiatives Substance abuse and parenting education Alternative to incarceration: “Fragile Families” curriculum presented by UHURU Short-term crisis housing for men abused by partners

Program-Level FindingsScreening and Assessments: 

Program-Level Findings Screening and Assessments

Program-Level FindingsAssessment and Follow-Up: 

Program-Level Findings Assessment and Follow-Up

Program Level Findings: Reported Abuse(N=64 women who screened positive for violence in a prenatal visit): 

Program Level Findings: Reported Abuse (N=64 women who screened positive for violence in a prenatal visit)

Frequency of Abuse Among Women Assessed During Pregnancy: 

Frequency of Abuse Among Women Assessed During Pregnancy

Program Level Outcomes: 

Program Level Outcomes Women screening positive who were assessed for FV were screened for depression During pregnancy and At six-weeks postpartum Women in all four categories showed improvement between prenatal and postpartum depression scores: Emotional abuse Physical abuse (least improvement) Sexual abuse (greatest improvement) Any abuse Reasons for better scores may include use of FV services provided in prenatal clinic and by project

Program Level Outcomes: 

Program Level Outcomes Birth Outcomes 25 women were assessed 6 weeks postpartum 23 live births, 2 miscarriages No record of LBW (8 missing data) 7 preterm births 6 maternal health problems at/after delivery 3 infant complications at delivery Mother attributed miscarriage to abuse

Program Level Outcomes: Satisfaction: 

Program Level Outcomes: Satisfaction 25 women assessed at 6 weeks postpartum were asked about services

System Level Findings: 

System Level Findings The aim of the project was not only to provide services and collect quantitative data, but to effect system-level changes and sustainability for efforts to reduce and eradicate family violence beyond the life of the project. Neither element stands alone. Reducing violence, perinatal depression and poor birth outcomes requires targeted clinical interventions supported by community concern and action.

System-Level Findings: 

System-Level Findings FV Screening in PNC clinic is feasible and acceptable Establishing Policies and Procedures was key In-Take, Screening, Treatment, Referral, Follow-up Working with Partners outside Health Sector necessary for multi-dimensional problem Courts, MH, Child services Shelters, crisis centers Fatherhood Initiatives Churches

System-Level FindingsSurvey of Providers: 

System-Level Findings Survey of Providers Education and Training Majority of partners participated in project-sponsored FV education and training Most found training to be useful Respondents were knowledgeable about NC ranks in top ten among states for FV deaths FV homicide is #1 cause of death for pregnant women Emotional abuse is most common type Knowledge of harmful effects on fetus will motivate woman to seek help

Clinicians’ Change in Comfort with Family Violence Systems-Level Survey of Providers (n=18), 2005: 

Clinicians’ Change in Comfort with Family Violence Systems-Level Survey of Providers (n=18), 2005

Overall Work of the BLP FV ProjectProfessional Development-Level Outcomes: 

Overall Work of the BLP FV Project Professional Development-Level Outcomes Increased personal knowledge about FV issues (93%) Strengthened professional skills (62%) Broadened base of professional ties (62%) Enhanced leadership abilities to speak and act on behalf of family violence issues (52%)

Sustainability: 

Sustainability LHSAP FV Addressed by Consortium’s Action Plan System-level changes post-grant Policies and procedures in place Staff screening and referral training Regional FV Network is Coordinating Body Case managers for PNC and ICC continue to include FV as an important feature of their services

Lessons Learned: Project Context: 

Lessons Learned: Project Context Pregnancy is a key family event May trigger or escalate tendencies toward abuse Therefore, PNC is important time to enhance services Importance of faith community Pastors can play an integral role Disseminating information and educating the community Offering counseling Making referrals for professional assistance Pastors frequently lack appropriate FV training

Lessons Learned: Project Context: 

Lessons Learned: Project Context The rural situation With limited resources, community partners must share burden Identification and follow-up is responsibility of all partners Rural women are like urban women Experience stress in relationships and economic status Need to fill multiple roles Desire to prevent unwanted pregnancies Rural women differ from urban women Have limited options to access confidential services Face both isolation and lack of privacy in seeking care

Lessons Learned: Project Design: 

Lessons Learned: Project Design Networks of care Providers must acknowledge each other’s roles and domains explicitly to establish networks where Referral and service provision occur routinely and effectively More families receive needed services Partnerships across public health, faith, law enforcement social and judicial providers Are feasible Work to create effective and enduring programs

Lessons Learned: Project Design: 

Lessons Learned: Project Design Networks of care, continued Resources targeted at rural pregnant women are scarce. Collaboration among agencies enhances the likelihood of effective services being offered to rural clients. A 2005 study of the 19 National Centers of Excellence in Women’s Health found none offered behavioral or mental health services targeted to rural women.

Lessons Learned: Project Design: 

Lessons Learned: Project Design Men Generally DO understand issues and factors leading to FV Want to know how to play a more dynamic role in Prevention Peer-to-peer counseling Have needs of their own and experience stress related to pregnancy and growing family Are better able to manage stress and meet expectations when they Receive training in family dynamics/communication Know that support is available for them, too.

Lessons Learned: Project Design: 

Lessons Learned: Project Design Staff Require education and training to treat abused patients appropriately Own experience of FV may affect ability to provide effective services Training must be sensitive to their experiences When asked what they would do if they experienced FV Professionals’ response may be ambivalent or vary from protocols they have learned. Appalachian study found rates of childhood abuse higher among healthcare workers than among pregnant women.

Lessons Learned: Implementation: 

Lessons Learned: Implementation Specialized Services in PH Maternity Clinic Provides multi-level training for staff Initial Refresher and remedial Up-dated Evaluates patients for FV and substance abuse Provides direct services to pregnant and postpartum women Ensures continued implementation of policies and protocols

Lessons Learned: Sustainability: 

Lessons Learned: Sustainability Although rural areas are often unable to support multi-disciplinary agencies and organizations… They can produce similar breadth of service through collaboration And by creating multi-disciplinary workgroups Effective linkages include: Fatherhood programs Infant mortality / Child Fatality boards Local churches Schools Criminal justice agencies Drug and alcohol treatment programs Crisis centers and shelters Public Health clinics

Healthy Start Components: 

Healthy Start Components Healthy Start components provide an excellent infrastructure for projects addressing community needs. Modestly funded grants (e.g., SPRANS, local foundations) benefit from use of HS components to expedite project timelines. HS models ensure community involvement, cultural sensitivity and access to care.

To continue the discussion…: 

To continue the discussion… If you have ideas to share or questions, please contact Ellen Shanahan, MA UNC-CH Sheps Center phone 919 966 8445 Ellen_Shanahan@unc.edu Julie DeClerque, DrPH UNC-CH Sheps Center phone 919 966 7106 Julie_DeClerque@unc.edu