Healthy Start and CHW Evaluation MiCHWA Annual Meeting Lansing Community College October 9, 2013
History of Healthy Start Created under HRSA s MCHB in 1991 to reduce infant mortality & improve MCH in areas with highest IMR and racial disparities Began with 15 demonstration sites, now 105 in 38 states, Puerto Rico, and WDC Seven HS in Michigan
Healthy Start Model Comprehensive model that uses home visiting as a service delivery component Uses place-based systems approach Based on Life Course Perspective Socio-ecologic framework Serves >78,000 women per year IMR of 5.1 / 1000 is lower than US 6.7
Goals & Objectives Reduce infant mortality Reduce low birth weight rates Increase the number of women with adequate prenatal care Increase access to mental health Increase the number of pregnancies spaced at least 18 months apart
Goals & Objectives Increase the number of women & children with a medical home Educate community and health care providers Foster consumer and family participation Improve the overall system of care Promote racial equity
Participants Program Participants: Pregnant women Interconception women (enrolled for two years after delivery) Infants and children under two years of age Community Participants: People who attend events sponsored by HS
Core Components Service Level Outreach Case Management Inter-Conception Care Health Education Depression Screening & Referral Systems Level Consortium (incl. consumers) Local Health System Action Plan Collaboration w/ Local & State Agencies Sustainability
Core Components Flexibility in how implement based on local needs, resources and priorities. But all are: Community-driven to ensure project is relevant and responsive to the realities of life Service-focused to provide needed care, meet basic needs, and promote self-sufficiency Address SDoH and work to enhance health care infrastructure and service system
Service Level Core Services: Outreach Community Health Workers / Peer Mentors Identify women at risk and connect to needed services Build long-term relationships Home visits for social support, education and referrals
Service Level Core Services: Case Management Home visits by CHWs, RNs and SWs (MIHP) for prenatal and inter-conception women Develop goals, provide counseling and education Link to needed services (GED, housing, food, education, insurance, FP, transportation, etc.)
Service Level Core Services: Education Program participants Family members Community residents Agency staff Health care providers Service providers Students, church members, child care providers SB: EBP, Safe Sleep Facilitator, YGG!, quarterly community education >1,650 / year
Service Level Core Services: Mental Health Screen & refer for perinatal depression SB Mental Health Coordinator: Crisis management Individual counseling Six-week therapeutic support groups on stress, depression & anger mgt
Additional Components Brush Up for Baby Breastfeeding support groups (co-facilitated by CHWs) Fatherhood program (home visits by male CHW)
Systems-Level Consortium consumers, partners, providers, business, clergy, universities, WIC, etc. LHSAP (e.g., FIMR, GSC, Healthy Homes Coalition, PRFC, GGREN) Collaboration with state agencies (e.g., MiCHWA, PRAMS, PRIME, MCMCH) Advocacy - local, state & national
CHW Role in Strong Beginnings Community Outreach Enroll clients, complete assessments help develop care plans & monitor progress towards goals Social support, listening ear Members of case management team, case conference, support & enhance work by MIHP CM Health educators (individual and community)
CHW Role in Strong Beginnings Assist with mental health therapeutic support groups Complete Reproductive Life Plans Monitor birth control use & anticipatory guidance Help enroll in Medicaid, WIC, Plan First! Form part of CQI teams
CHW Role in Strong Beginnings Advocates & referrals for needed services (health care, GED, housing, food, employment) Arrange wrap-around services such as transportation Connect to mental health, BUFB, and Fatherhood Breastfeeding peer counselors Members FIMR Case Review Team Meet with state and federal legislators
CHW Training CHW Certification Ohio NCSC Healthy Families America Motivational interviewing HiPAA & Mandated Reporter Breastfeeding peer counselors Family planning, birth control & RLP Infant care, safe sleep, CPR, infant massage
CHW Training Mental health, substance abuse, IPV Baby Basics and Partners for a Healthy Baby curricula Healthy homes & lead poisoning Health equity / social justice On-going in-services & conferences New CHWs shadow & mentored by experienced CHWs
Value of CHWs Many former program participants - first hand knowledge of program All represent the pop. they serve Trusted leaders in the community Bring personal as well as professional expertise that complements RN/SW case managers Male CHW helps strengthen father involvement, communication, and parenting skills
Value of CHWs Smaller caseloads, more frequent visits than MIHP Serve as realistic role models Develop unique trust relationships with clients Engage highest risk women (lower no-show rates)
Value of CHWs Better utilization of health services Improved outcomes especially LBW, breastfeeding, child spacing, mental health Significant cost savings from improved outcomes
Vulnerable Clients Compared to African American pregnant women on Medicaid in Kent County, Strong Beginnings clients are statistically more likely to: Be unmarried Be in poverty Have an unwanted pregnancy Smoke and use drugs Have a clinical diagnosis of depression Have had a prior poor pregnancy outcome Be homeless and move more frequently Be in abusive relationships
Outcomes: Service Utilization Compared to other African Americans on Medicaid in Kent County, SB clients have higher rates of: First trimester prenatal care (80% vs. 58%) Adequate and Adequate Plus prenatal care (75% vs. 69%) Post Partum exams (70% vs. 57%) Well Child Visits (92% of SB infants had seven or more well child visits vs. 79% non-clients)
Outcomes: Breastfeeding
Outcomes: Child Spacing In Grand Rapids, 28% of African American women become pregnant within 18 months of delivery, down from 34% in 2008 (2010 data) Only 9% of SB participants became pregnant within 18 months of delivery
Grand Rapids Infant Mortality Black and White IMR - Three Year Averages 25 22.4 20 Black 18.9 Rate per 1,000 live births 15 10 7.5 Total White 5 3.6 0 2001-03 2002-04 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009 2008-2010 White 7.5 7 5.1 3.5 3.6 4.5 4.4 5.1 Black 22.4 21.4 18.4 18.2 18.9 17.7 17.3 16.7 Source: MDCH, Division of Vital Records and Health Statistics
Infant Mortality Rate (IMR) Moving average per 1000 live births Strong Beginnings and Grand Rapids Black IMR 50 40 Rate per 1,000 live births 30 20 18.3 17.9 17.6 Grand Rapids Black IMR Strong Beginnins 10 9.8 9.1 9.5 8.5 7.4 0 2005-2008 2005-2009 2005-2010 2005-2011 2005-2012 -Strong Beginnings 2005-2009: 5 infant deaths among 546 live births 2005-2011: 6 deaths /705 births (3 unpreventable birth defects)
Percent Low Birth-Weight Births (Weighing less than 2,500 grams or 5.5 lbs) Strong Beginnings and Grand Rapids African American LBW births 50 40 30 Percent Grand Rapids Black Strong Beginnings 20 10 1616.7 15.2 11.4 13 10 13.9 13.5 8.6 5.8 14.4 8.7 16.7 5.6 8.5 0 2005 2006 2007 2008 2009 2010 2011 2012
Percent Very Low Birth Weight Births (Weighing less than 1500 gm or 3.3 lbs) Percent Strong Beginnings and Grand Rapids African American VLBW births 10 Percent 5 4.4 4 3.8 3.5 3.9 4.1 Grand Rapids Black VLBW Strong Beginnings 2 2.4 2 0.93 1.1 0 0.17 0 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2008, 2009, 2011 Strong Beginnings VLBW = 0 Overall 2005-2012 VLBW = 0.98 (8/810)
Multi-Disciplinary Team Approach -- In Genesee County, CHWs are an integral part of our case management team Team consists of a community health worker (CHW), dietitian, nurse, and social worker Combines the skills and expertise of each team member Provides comprehensive service delivery to our moms and babies Service is individually based according to each family situation Assessments, screenings & other case information is shared by all members of the team The team holds a case conference once each month to update one another on progress and challenges Home visit frequency, by each team member and in total, is dependent upon the current needs of the family
Impact of Social Determinants in Flint and the Role of CHWs Risk Assessment Results Top 4 domains (Education/Career, Mental Health, Social Support, Housing) are not (or not effectively) addressed through traditional clinical interventions. Risk factors are not commonly singular. Top 3 Low Of 601 women, about 2% (10 women) scored high for risk in Adult Safety. About 2% (11 women) scored high for risk in Chronic Disease. 2.5% (15 women) scored high for risk in Disabilities. Top 3 High Of 601 women, 22% (133 women) scored high for risk in Education and Career. 13% (79 women) scored high for risk in Mental Health. 9% (56 women) scored high for risk in Social Support & Faith. Genesee County Health Department Program strategies must address all social determinants concurrently. Access to community based resources is critical to health improvement. CHWs are critical to addressing social determinants. This poster is supported by the Genesee County Health Department through the Healthy Start project, Grant Number H49MC00148-09-03, from the Department of Health and Human Services, Health Resources and Services Administration (HRSA).
CHWs outreach, recruitment, enrollment advocacy and support instrumental in engaging & maintaining participation transportation to medical appointments, WIC, community resources focus on basic needs assure access to organizations referral follow up Dietitians assess and educate nutrition of mothers and babies develop food plans for special health needs, diabetes, cardiovascular assess and monitor appropriate growth of babies and weight gain of pregnant women educate mothers about healthy weight after pregnancy Nurses focus on medical issues assess and monitor growth and development of babies monitor maternal health provide education and expertise for common but sometimes critical health issues such as gestational diabetes and high blood pressure Masters Level Social Workers (MSW) provide a focus on the psycho-social needs of mother and baby assess and educate mental well-being stress, family relationships and parenting domestic violence and substance abuse assess child growth and development help families access community resources Genesee County Health Department (GCHD) lead coordinating organization and fiduciary central client records and database, all federal reporting works with case coordination/case management team coordinates and performs outreach and health education services Christ Enrichment Center (CEC) joined our project in October 2012 to build stronger community connections to the population we serve October 2013 two additional part-time CHWs were added to coordinate the consortium and the men s project women s educational and support groups men s project - mentoring, fatherhood, systems advocacy coordinates community consortium and faith-based activities
CHWs and Social Determinants of Health The social determinants of health are the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. (CDC website) CHWs know the neighborhoods and understand how systems affect the lives of our families. Our mothers look to the CHWs for help and guidance. Educator Advocate Mentor GCHS CHWs are critical to our success. They fill many roles in the lives of our families.. Coach Role Model Support
PERCENT PERCENT 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 6.0% 4.0% 2.0% 0.0% LOW BIRTH WEIGHT (LBW) of African American Babies 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 VERY LOW BIRTH WEIGHT (VLBW) of African American Babies 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Genesee County Healthy Start vs. City of Flint African American Infant Mortality Rates Source: Genesee County Health Department Healthy Start participant data. City of Flint population includes Healthy Start participants. GCHS Achievements CITY OF FLINT HEALTHY START CITY OF FLINT HEALTHY START Between 2001 and 2010 the Genesee County Healthy Start Project served 1,790 pregnant women, 1,107 interconceptional women, 1,260 infants less than one year of age, and 669 children between one and two years of age for a total of 4,826 service recipients. Genesee County Healthy Start program participants consistently demonstrated better birth outcomes in comparison to the outcomes among African American residents in the project area. During the project period (2001 to 2010), very low birth weight (VLBW) among Healthy Start program participants was one-half the rate of other African Americans in the project area (1.7% compared to 3.4%), and the low birth weight (LBW) among program participants averaged 12.3% compared to 16.2% among other African Americans in the project area. Perhaps the most striking difference has been in the infant mortality rates. The IMR among Healthy Start program participants was almost seven times less than their counterparts in the project area (2.8 compared to 18.3 per 1,000 live births) over the ten-year period.
GCHS Goals 2011-2020 (include promoting CHWs) The next 10 years of Genesee County Healthy Start will build on lessons learned A Progressive Referral and experience gained from the first 10 years. Nine goals summarize our focus Network: and direction for the future: Goal 1: Identify opportunities to maximize community resources and advance local referral system. Goal 2: Increase community partnerships and strengthen connections with current partners. Goal 3: Broaden connections to all sectors of the community to increase resources. Goal 4: Develop foundational strategies among other programs to increase emphasis on mothers stress level and lack of positive social support. Goal 5: Maintain alliances with the Maternal Infant Health Program to emphasize the importance of funding maternal/infant home visiting services and related programs. Goal 6: Promote awareness of the value of community health workers. Goal 7: Identify opportunities to expand advocacy of policies regarding improved access to adequate/safe housing and utility assistance. Goal 8: Promote awareness of social determinants of health as the key to improving maternal/infant health. Goal 9: Showcase successes though increased local evaluation and publishing to expand sustainability opportunities. Assisted Referrals following the client through the course of their contacts and appointments. More connected referral network working with agencies to increase use of each other s services and create a net of support for each client. Navigation support decentralized over time client will learn skills of self support and advocacy, creating a base of community members and mothers who are empowered.
Maajtaag Mnobmaadzid The Inter-Tribal Council of Michigan Healthy Start Project
Who We Are Inter-Tribal Council of Michigan, Inc. A 501 (c) (3) organization (a Tribal Consortium) composed of eleven federally recognized Indian Tribes in Michigan.
Who We Are Maajtaag Mnobmaadzid Since late 1997, ITCMI has been administering Maajtaag Mnobmaadzid: The Start of a Healthy Life. A home visiting, case management program for Native American pregnant and postpartum women and infants. 8 sites throughout 14 counties in Michigan 6 Tribal 2 Urban
Home or office visits by a maternal child health nurse to provide screening, assessment and education Innovative, holistic and culturally appropriate interventions that are specifically tailored to each client and address risky behaviors Health promotion, childbirth and parenting education Case management services including referral, follow-up and after-care services for a variety of family needs Transportation assistance Support & Advocacy Provided Services
CHW Provided Services Accompany nurse on home or office visits on first time visits, if unfamiliar area, or in isolated rural areas for safety and community entry families will sometimes open door for CHW but not others; Involved in recruitment: field word of mouth and informal referrals; Locating lost to follow up clients: use community knowledge to locate hard to reach clients; Case management follow-up: checking back to see if pursued referral, if need transport, drop of incentives, emergency supplies Transportation assistance Support & Advocacy
Focused CHW Provided Services Two of our CHWs have taken a special interest in breastfeeding support and have obtained their CLC Certified Lactation Counselor credential In addition to providing one on one lactation support, they run breastfeeding support groups, have become involved in advocating for work place breastfeeding policy, and initiated breastfeeding friendly actvities at community events Baby Breastaurant at Pow Wow s, etc. MICHIGAN INTER-TRIBAL COUNCIL
Community Level Activities involving CHWs Community health promotion and risk reduction events Health education counseling for teens and their families Advocacy through a statewide consortium of clients, service providers, community leadership, policy makers, & organizational partnerships Advocacy for system changes that will improve the quality and accessibility of care for Native American families
Program Successes The infant mortality rate among American Indians within the ITCMI s Healthy Start project area has dropped more than 50% since the start of the project. In 1996 the rate of 1rst trimester prenatal care for MITC project participants was at 74%. In 2005 the rate was 90.4%. This rate is higher than the statewide rate for Whites.
Strong Start. Healthy Start
*Program Awarded June, 2012 Mission: Eliminate infant mortality disparities and improve the health of families in the Ingham County area. *
*Workshops held weekly at 3 of the Lansing subsidized housing sites *Peer Advisors from each site assist Health Educator with workshops *Peer Advisors are women who live in the community that are recognized as leaders or supporters of their community *2012-2013 Over 90 families participated *
WHY IS OUR COMMUNITY SICK? YOUR THOUGHTS. YOUR PHOTO. YOUR VOICE. Creating Community Dialogue Around Issues that Affect Infant Mortality *
Case Management: Maternal Infant Health Program * High Risk * African American woman * Experienced a negative pregnancy outcome * Services provided by both Public Health Nurse and Public Health Advocate for 2 years post partum * At Risk: * African American woman of childbearing years * Services provided by either Public Health Nurse or Public Health Advocate * 2012-2013 Implementation Year * Over 50 Women and their families served *
* *Facilitate discussion of perceived racism and its relationship to chronic stress. *Provide information related to effects of chronic stress. *Utilize motivational interviewing to identify barriers *Provide positive affirmations to facilitate achieving goals. Supporting women and families in overcoming barriers and reaching their goals.
MiCHWA CHW Common Program (Process and Outcome) Indicators Telling the CHW story with NUMBERS
What are common indicators? Putting a number to what CHW s do (process indicators) Putting a number to what happens to clients/patients when they do what they do (outcome indicators) The potential POWER of all our numbers
Why CHW Common Indicators? Critical point in time The U.S. can t afford health care as we know it Openness to alternative ways to deliver health care; other health team members Attention to the social determinants of health Health literacy obtain, process and understand health information and services to make appropriate health decisions Primary care and patient-centered Medical Home
Why CHW Common Indicators? Investments in evidence-based interventions Example: the MI Maternal and Infant Health Program and the state legislature (18,000 pregnant women in 82 MI counties; 50% second time moms) Time to persuade: taking numbers to policymakers and payors Example: Food insecurity
Why is getting numbers so hard? Lack of clarity about the scope of CHW work Many activities address social determinants, not well defined, time consuming, hard to measure and put a number on Data sources---warehouses for medical and nursing care tied to reimbursement MIHP as an example (some also served by CHW) Using the same yardstick for nurses, CHWs, social workers and others
Why is getting numbers so hard? It feels like it is taking time away from our clients
How will data be used? CHWs provided X (time) care to x number of Michiganders; The health of CHW clients are impacted by poverty and racism (% Medicaid insured; % < 133% level; % racial/ethnic minority) CHWs helped % people with low health literacy learn to use primary care versus the emergency department
Picking common indicators? How do others define CHW roles and functions? State groups? Researchers? CHW groups? Ask programs what they count! What indicators are they required to count Healthy Start performance measures: 3 rd trimester tobacco use; postpartum visit; Ask CHWs what they do!
What do CHWs say they do? Self-Management /Health literacy Discussed what happened at last medical prenatal visit Discussed when to call the doctor Prepared mother with what to expect at next medical prenatal visit Translated medical provider information Translated MIHP case manager information Accompanied client to: Community resource for basic needs DHS Doctor office Group education session Mental health appointment Other
What do CHWs say they do? Medicaid Outreach/Navigation: Arranging language translation services ; translating forms Arranging transportation Completing DHS forms Completing insurance forms; change in Medicaid; provider Completing medical forms Contacting DHS worker on behalf of client Engaging/retaining client in other Medicaid services Finding a medical provider (physician or dentist) Making medical appointments Teaching client how to use MHP transportation
Basic needs Assisted with acquiring or maintaining housing (did more than a referral) Assisted with acquiring or maintaining utilities Assisted with getting access to a phone Assisted with securing food (food pantry, WIC, food stamps did more than a referral) Picked-up or distributed supplies Social support - listened to client, showed concern, gave moral support, gave encouragement
CHW impact in the new health care system : an example The next slides provide some numbers about where some Medicaid insured women are receiving health care after they have a baby How could CHWs target the problem of emergency department visits and engage women in a medical home? How could CHWs count their successes? How interested would Medicaid health plans be in your numbers?
Postpartum Visit by Race/Ethnicity Kent Total (4,484) Black (928) Other (3,556) N % N % N % Postpartum visit 2,235 49.84 472 50.86 1,763 49.58 Postpartum Visit by Medicaid Status Kent Total (4,484) Medicaid before Pregnancy (2,262) No Medicaid before Pregnancy (2,222) N % N % N % Postpartum visit 2,235 49.84 1,274 56.32 961 43.25 63
Postpartum ED 61 st -365 th Days After Birth by Medicaid Status Kent Total (2,148) Medicaid before pregnancy (835) No Medicaid before Pregnancy (1,313) N % N % N % Postnatal ED: 61 st 365 th days after birth 985 45.86 426 51.02 559 42.57 # of postnatal ED visits None 1,163 54.14 409 48.98 754 57.43 1 409 19.04 162 19.40 247 18.81 2 214 9.96 101 12.10 113 8.61 3 or 4 193 8.99 91 10.90 102 7.77 5 or more 169 7.87 72 8.62 97 7.39 64
What Medicaid managed care likes Johnson, D et al. Community Health Workers and Medicaid Managed Care in New Mexico. Journal of Community Health, Published online 28 September 2011
Common Indicators Next Steps CHW survey Ask program directors what data they are collecting now for current funders? Give them a checklist to briefly scan Ask them to tell us what is missing or more detail (using a health literacy question; and ED diversion, a medical home indicator) Consensus MiCHWA group for a starter list
Common Indicators Talk to us! Help us understand your concerns about collecting more data What do you think we should be collecting? How should we be collecting data? What would make it easier for you as a program? As a CHW?