Lisa Schlar, MD Director of Womens Health UPMC Shadyside Family Medicine Residency Pittsburgh, PA

Jessica Brubach, ICC Project Coordinator FMEC IMPLICIT Network

Objectives
Introduce IMPLICIT Network Examine rationale, evidence and benefits

of interconception care (ICC) strategies Present ICC Model Report initial outcomes Provide ICC tools Discuss challenges

IMPLICIT NETWORK
Interventions to Minimize Preterm and Low Birth Weight Infants using Continuous Improvement Techniques
Initiated Fall 2003 Collaboration of family medicine

residency programs
Evidence-based prenatal

interventions to reduce LBW/prematurity

Goal to restructure curriculum and

practice to improve quality of care and patient outcomes

Family Medicine IMPLICIT Network

in collaboration with March of Dimes and Family Medicine Education Consortium

Prenatal Care: The Dilemma

By the time a woman enters prenatal care, it is often too late to significantly affect the outcome of the pregnancy.
Neural tube closes 28 days after

conception
Placental development begins 7 days

after conception

INTERCONCEPTION CARE: Rationale

National Priority CDC MOD Early and adequate prenatal care doesnt

reduce LBW/prematurity Unintended pregnancies : Increased detrimental prenatal behaviors Increased risk of preterm and low birth weight (LBW) babies Negative health & social outcomes for mother and child Short interpregnancy intervals (<18 months) Increased risk of preterm, LBW, SGA
Lu et al, 2006 / Conde-Agudelo et al, 2006/Muchowski et al, 2004

Barriers to Interconception Care

No access to care Lack of insurance No established model No clinician time to address Focus is on the infant
Heneghan et al, 2007/ La Rocco et al, 2003; Kahn et al., 1999, Muchowski, et al, 2004

MATERNAL SCREENING During WCV - Evidence

Mothers take child to WCV without caring for self
Majority accept inquiry about own health at WCV Maternal tobacco screening at WCV showed high

rates of use impact on child Maternal depression screening & referral at WCV + impact on child

Gjerdingen et al, 2009/Heneghan et al, 2007/Roske et al, 2009

Family Physicians are Best Equipped to Provide Interconception Care

Mothers Health During WCV Baseline Survey 2011 (N=672)

I believe that my health affects the health of my children and children from future pregnancies.
True False

82.0%
18.0%

I am willing to take advice about my health that affect my children from my childs doctor.
True False

94.5% 5.5%

IMPLICIT ICC Baseline Survey

Maternal Demographics (N=672)

Majority
are seen in our offices (75.7%) with Medicaid insurance (73.93%) African Americans or Latino (66.3%) Finished: some college, no degree (30.77%)

high school (30.77%)

Young moms: 25.00% were < 22 y/o at childs birth

IMPLICIT ICC MODEL

ICC focuses on 4 behavioral risks
Smoking Depression Family Planning Multivitamin w/Folic Acid Use

 20% of smokers quit during pregnancy

IMPLICIT ICC Strategy: Smoking Cessation

70% who quit will relapse within 6 mos PP Assess maternal smoking status Recommend cessation BEFORE (the next) pregnancy

using 5 As: Ask Advise to quit Assess willingness to quit within 30 days Assist with ways to quit Arrange follow-up
Lumley J, et al, 2007/ Muchowski et al. 2004/Windsor RA, et al., 1993

IMPLICIT ICC Strategy Depression Screening

Sxs occur in 20-40% of women during or PP Depression has a peripartum recurrence of 40% Screen women for depression with PHQ-2

PHQ-9 if + PHQ-2 If + Depression:

Assess for safety and severity of symptoms

Refer immediately if any suicidality or homicidality is

present Arrange for follow-up and services

Bennett IM, et al, 2010/Chung EK, et al, 2004/ Murray L, et al, 2003/Weissman MM, et al, 2006

IMPLICIT ICC Strategy Family Planning

Unintended pregnancies and short IPI

assoc w/ risk of LBW/Prematurity Antenatal counseling doesnt improve use

Assess women for contraception use Educate about benefits of longer IPI Offer contraception or arrange appointment

or referral
Conde-Agudelo, et al, 2006/Smith, et al, 2002

IMPLICIT ICC Strategy Multivitamin w/Folic Acid Use

Routine folic acid supplementation reduces

the rate of NTD by 66%, MVI even more MVI w/folic acid assoc with 50% - 70% less PTB Only 24% of US women consume; Only 1 in 5 know
Assess MVI w/folic acid use Rx MVI w/ folic acid to all women
Czeizel, AE, et al, 2004/De-Regil, LM , 2010/Muchowski et al, 2004/Tinker SC, et al, 2003

IMPLICIT ICC Strategy

Utilize contact with mothers at WCV

Assess current risks at each WCV 0-24 mo

Reinforce desired behaviors

Connect with primary providers or

community resources to address risks

Collect and analyze data and develop

strategies to improve care delivery

Initial Network Outcomes

(since 2012)

Live at 8 Network sites Trained more than 400 providers Screened for ICC more than 5,500

times Follow more than 2,800 unique mothers Going live at more 8 sites by Summer 2014

Initial Network Outcomes

Behavioral Risk Factor (N=715) Smoking Depression Positive (+) Screen Counseling/Treatment
(% of visits) (% of visits)

30.25% 11.90%

94.90% 100.00%

Lack of Contraception
Not on Multivitamin

20.0%
53.50%

79.90%
59.60%

Key ICC Processes

Assessments must be systematic & efficient Assign members of your team Establish plans at how to address positive

screens, including response to suicidality Screen at every visit to increase rates Make patient/provider education part of plan If part of CQI, it must be measured, make your EMR do the work Give ongoing feedback to team

ICC Tools Create Office Flows

ICC Tools Create Office Flows

Mother presents with child (age 0-2) for well child visit

Smartphrase .icc performed by provider during childs exam

Negative Screen

Pos screen: brochure and open moms chart

Mother Reports Smoking Mother not taking daily PNV Positive screen for Depression Lack of Family Planning

Usual well child care

Smoking Cessation Resources and Quit Line Information given to mother

Rx for prenatal vitamin or give supply of prenatal vitamins to mother

Assess for suicidal ideation

Inform mother of recommendations to wait until 18 months to conceive

Negative

Positive

Provide contraceptive information and /or schedule follow-up visit

Schedule follow-up appointment or send referral form to PCP/prescribe meds

Assess need for immediate intervention

ICC Tools Calculate Monthly Screening Rates

ICC Tools Patient Education

ICC Tools Utilize your EMR

ICC Tools Give Monthly Provider Feedback

Monthly ICC Implementation Rates for Valencia, Ria
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100.0% 100.0% 77.8% 100.0%

Implementation Rate

Aug-12

Sep-12

Oct-12

Nov-12

Month
Well Child Visit Report Provider Valencia, Ria Total Number of WCV Total Number of WCV with ICC Month Aug-12 Sep-12 Oct-12 Nov-12 Total 1 1 1 1 9 7 2 2 13 11

Overall ICC Implementation Rate: 84.6% ICC Implementation Rate Goal: 75%

ICC Implementation Challenges

Lack of provider engagement
Generate awareness, interest,

competence

Family docs in unique position to care

for mother and infant

Peds can do with education and referrals

Performing ICC without an EMR

Use paper tool, manual chart review

Conclusion
1. IMPLICIT ICC is a brief, efficient, innovative strategy to 2.

3. 4. 5. 6. 7.

improve maternal health prior to the next pregnancy Screening and treating mothers with tobacco use, depression, without contraception or multivitamins during WCV can improve birth outcomes Data driven care is critical to effective CQI initiatives Need a systematic approach to screening, data collection, analysis and feedback Essential to have dedicated multidisciplinary team Need funds for admin personnel Ongoing monitoring of identified maternal health risks to reinforce desired behaviors and offer interventions will improve overall maternal health and ultimately reduce the risk of LBW/premature infants

Preventing Prematurity One Woman at a Time

10 years later10,000 women in the database

Want To Learn More About The IMPLICIT Network Interconception Care (ICC) Project?

Please visit fmec.net or Contact Jessica Brubach, ICC Project Coordinator brubachjl2@upmc.edu

 Bennett IM, Marcus S, Palmer S, Coyne JC. Pregnancy related discontinuation of antidepressant use and depression care visits among Medicaid recipients. Psychiatric Services. April 2010;61(4)386-91. PMID 20360278. Chung EK, McCollum KF, Elo IT, Lee HJ, Culhane JF. Maternal depressive symptoms and infant health practices among low-income women. Pediatrics. 2004;113:e523-9. Conde-Agudelo,A., et al. Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis. JAMA, April 2006; 295:1809-23. Czeizel, AE. The primary prevention of birth defects: Multivitamins or folic acid? Int J Med Sci. 2004;1(1):50-61. De-Regil, LM, Fernndez-Gaxiola, AC, Dowswell, T, & Pea-Rosas, JP. Effects and safety of preiconceptional folate supplementation for preventing birth defects. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD007950 Gjerdingen D, et al. Postpartum Depression Screening at Well-Child Visits: Validity of a 2Question Screen and the PHQ-9. Ann Fam Med, 2009. Heneghan A., et al. Paediatricians Attitudes about Discussing Maternal Depression During a Paediatric Primary Care Visit. Child: Care, Health & Development 2007. Kahn R. & Wide P. The scope of unmet maternal health needs in pediatric settings. Pediatrics, 1999. LaRocco A., et al. Depression screening attitudes and practices among obstetriciangynecologists. Obstet Gynecol, 2003. Lu M., et al. Preconception care between pregnancies: the content of internal care. Matern Child Health J, 2006.

REFERENCE

REFERENCE
Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. The Cochrane Database for Systematic Reviews. Volume (3), 2004. Accessed online on 3/28/07. Muchowski K., et al. An ounce of prevention: The evidence supporting periconception health care. The Journal of Family Practice, 2004. Murray L, Cooper PJ, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child relationship and child outcome. Br J Psychiatry. 2003;182:420-7. Roske K., et al. Smoking Cessation Counselling for Pregnant &Postpartum Women among Midwives, Gynaecologists and Paediatricians in Germany. Int J Environ Res Public Health, 2009. Smith, KB, et al. Is Postpartum Contraception Advice Given Antenatally of Value in Contraception, 2002 Tinker SC, Cogswell ME, Devine O, Berry RJ: Folic acid intake among U.S. women aged 1544 years, National Health and Nutrition Examination Survey, 2003-2006. Weissman MM, Pilowsky DJ, Wickramaratne PJ, Warner V, Pilowsky D, Verdeli H. Remissions in maternal depression and child psychopathology: a STAR*D-child report. JAMA. 2006;295:1389-98. Windsor RA, Lowe JB, Perkins LL, et al. Health education for pregnant smokers: its behavioral impact and cost benefit. Am J Public Health 1993;83: 201-206.