Putting it All Together - PowerPoint Presentation

Putting it All Together: How We Can Meld Our Passion into More Effective Work Presentation by Kay JohnsonDelaware Healthy Mother & Infant Consortium (DHMIC) Annual SummitChanging the Trajectory of the Next Generation April 4. 2017 1 K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017

For decades we believed that if we improved access to and use of effective contraception and quality prenatal care, then we could influence disparities in the health of women and infants. This is true in some ways BUT Now we know much more needs to be done to reverse the cumulative disadvantages and inequities that occur over the life course of many women.2 K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017

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So, what is not happening that should be? Low reproductive health awareness or no “reproductive life plan” for most men and women.Young adults in working class still uninsured.Primary care discontinuous (no medical home).Majority of women have coverage for well visits with preconception care, but they and their providers are not aware, not benefiting.Many providers not focused on reproductive risks, preconception health, or recurring risks for adverse pregnancy outcomes.Unequal treatment and health inequities drive racial/ethnic and income disparities.5

Common system failures Primary care providers not strong on preconception.Prenatal care quality receives too little emphasis.Interconception care devolves into LARC initiatives.Prevention of teen pregnancy but not weathering.Head separated from the body (oral & mental health).Perinatal HIV, opioid use, etc. marginalized.Perinatal QI mainly about hospitals and vital statistics.Home visiting not enough to affect index birth outcome. Developmental screening not done as recommended.SDOH & ACEs assessed but not addressed. 6 K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017

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Public Health Strategic Priorities The Delaware Division of Public Health is focused on the following strategic priorities related to maternal and child health, which are long-term systematic efforts:Infant Mortality – Delaware continues to have higher rates compared to the nation.Health Reform - All Delawareans deserve quality, comprehensive, coordinated, prevention-focused, culturally competent care.Health Inequities – Certain populations consistently have worse health outcomes compared to others.Healthy Lifestyles - Overweight and obesity have increased rapidly among children, youth and adults in the U.S.Social/emotional health and trauma-informed care are increasingly being recognized as a priority across disciplines K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 8

Delaware MCH Priorities 2015-2020Increase number of women who have a preventive visit to optimize the health of women before, between & beyond pregnancy.Improve breastfeeding rates.Improve rates of developmental screening in the healthcare setting using a validated screening tool.Increase healthy lifestyle behaviors.Increase the percent of children with and without special health care needs having a medical home .Address bullying among middle and high school age children by focusing on ways to reduce the mental health impacts. Improve the rate of o ral h ealth preventive care in pregnant women and children. Increase the percent of children 0-17 who are adequately insured . 9 K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017

SACIM Strategic Directions: 6 Big Ideas K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201710

1. Improve the health of women K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201711

Percent of Adults Age 18-64 with No Usual Source of Care, By Insurance Status, US, 1997-98 to 2013-14K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 12

Health coverage matters K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201713

2. Ensure access to a continuum of safe and high-quality, patient-centered care K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201714 IOM. Six Domains of Health Quality. Crossing the Quality Chasm . 2001. http:// www.nationalacademies.org/hmd/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx https:// www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html http :// www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmSixAimsforChangingtheHealthCareSystem.aspx Six Domains of Health Quality

Adopt Systems Integration Strategies K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201715

Use the power of “ONE”One key question One medical home One planOne care coordinator leadOne stop shoppingK Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201716

3. Redeploy effective, preventive interventions Social marketing, health education, and access to clinical and community preventive services. ImmunizationFamily planningBreastfeedingSafe sleep Smoking cessation What else? Newborn screening Folic acid 17P Developmental screening HIV screening & ARV K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 17 Source: SACIM (2013) Recommendations for Department of Health and Human Services (HHS) Action and Framework for a National Strategy . Strategic Direction 3. https://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/Correspondence/recommendationsjan2013.pdf

Implement “Two Gen” strategies K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201718To learn more, visit http://ascend.aspeninstitute.org/pages/the-two-generation-approach

4. Increase health equity and reduce disparities by targeting SDOH Not all health differences are health disparities.Health disparities are systematic, plausibly avoidable health differences according to income, race/ethnicity, religion, or socioeconomic position.Disparities in health and its determinants are the metric for assessing health equity. Health equity is the principle underlying a commitment to reducing disparities in health and its determinants.Health equity is social justice in health. K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 19 Source: Braveman et al. Health Disparities and Health Equity: The Issue Is Justice. Am J Public Health . 2011;101:S149–55 .

20 WHO defines SDOH as the circumstances in which people are born, live, and work, and the systems in place to deal with illness. Circumstances shaped by larger forces such as economics, public policies , and politics. Social Determinants of Health K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017

HEALTH Behaviors Medical Care Living & Working Conditions in Homes and Communities Economic & Social Opportunities and Resources -Reduce poverty & segregation. -Promote economic development in disadvantaged communities. -Promote child & youth development & education, infancy through college. -Job creation & training. Promote healthier homes, neighborhoods, schools & workplaces. Strengthen safety nets. Source : P. Braveman et al. University of CA., San Francisco, adapted from version originally created for: Overcoming obstacles to health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. Robert Wood Foundation, 2008 . Interactions between genes and experiences Achieving health equity by addressing SDOH K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 21

New ways to talk about SDOH “It’s time for America to lead again on health, and that means taking three steps. The first is to ensure that everyone can afford to see a doctor when they’re sick. The second is to build preventive care …into every health care plan and make it available to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy... The third is to stop thinking of health as something we get at the doctor’s office but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drink. The more you see the problem of health this way, the more opportunities you have to improve it . Scientists have found that the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor. ” K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 22

How can we tackle SDOH?Tax policy Family leave Medical-legal partnershipsHousing policy Health in all PoliciesK Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201723

Family Tax Credits Improve OutcomesK Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 24

K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 255. Invest in adequate research and data to measure access, quality, and outcomes Adapted from IHI: Solberg et al. The three faces of performance measurement: improvement, accountability , and research . The Joint Commission Journal on Quality Improvement . 1997;23(3):135‐147.

Three Types of Measurement Quality Improvement Performance & Results Accountability Evaluation & Research K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 Use of LARC Unequal treatment of neonates Key elements of postpartum visits Develop-mental screening referrals Rates for: Unintended pregnancy Births in risk appropriate facility Postpartum visits Develop-mental screening What is reproductive experience of women using LARC? How does NICU environment affect infant? What motivates postpartum visits? Validate tools for developmental screening 26

Innovations to Focus Monitoring K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201727

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6. Maximize interagency, public-private, and multi-disciplinary collaboration K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201729

Maximize Partnership Synergy By combining the perspectives, resources, and skills of partnership, the group creates something new and valuable together – a whole that is greater than the sum of its individual parts.”K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201730Lasker et al. Partnership Synergy. Milbank Quarterly. 2001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751192/

18% Committed Activists Equity Advocates 23% Health Egalitarians LOW HIGH NONE HIGH GOVERNMENT ROLE 17% Disinterested Skeptics PERSONAL HEALTH IMPORTANCE 14% Private-sector Champions Self-reliant Individuals Source: Exhibit 1. Bye L, Ghirardelli A, & Fontes A. Promoting health equity and population health: How Americans’ views differ. Health Affairs , 2016, Nov;35(11 ):1984. American Health Values Survey. RWJF. Typology of Americans ’ Health Values K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 31

Source: Exhibit 3. Bye L, Ghirardelli A, & Fontes A. Promoting health equity and population health: How Americans’ views differ. Health Affairs, 2016, Nov;35(11):1984. American Health Values Survey. RWJF. 32 K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017

K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 33Conclusion

A Vision for Improving Preconception Health and Pregnancy OutcomesAll women and men of childbearing age have high reproductive awareness. All women have a reproductive life plan.All pregnancies are intended and planned.All women of childbearing age have health coverage.All women of childbearing age are screened prior to pregnancy for risks related to outcomes.Women with a prior adverse pregnancy outcome have access to interconception care to reduce their risks.K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 34

Looking ahead, what can Delaware do? K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 201735

A Vision for Maternal and Child Health We envision an America where all children and families are healthy and thriving, and where every child and family have an equitable opportunity to reach their full potential.K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 36

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