The focus of the ICP is to provide enhanced case management services for high-risk women to ensure their optimal preconception health. Services are provided by public health nurses (PHN) and other health professionals that provide home visits, education, and needed referrals, as well as a dental component, wellness program and family planning services. ICP case management actually occurs through enhanced Home Visiting Program (HVP) visits by PHNs who have been equipped with the ICP training and tools.
Kent County Health Department
Interconception Care Program
The Kent County Health Department’s (KCHD) Interconception Care Program (ICP) serves the greater Grand Rapids, MI area. In response to the high infant mortality rate and other unacceptable poor birth outcomes plaguing the African American community, KCHD implemented the ICP to identify and enroll at-risk women to participate in home-based health care interventions during the interconception period. The long-term goal of the ICP is to reduce infant mortality and reduce the disparity in survival between African American and White infants by assisting women in achieving full-term, normal-weight births and planned pregnancies with at least an 18 month pregnancy interval. To date, the program has enrolled more than 300 women. Nearly 75% of ICP clients are non-White.
The focus of the ICP is to provide enhanced case management services for high-risk women to ensure their optimal preconception health. Services are provided by public health nurses (PHN) and other health professionals that provide home visits, education, and needed referrals, as well as a dental component, wellness program and family planning services. ICP case management actually occurs through enhanced Home Visiting Program (HVP) visits by PHNs who have been equipped with the ICP training and tools. The PHN case managers employ the Life Course Perspective for interpreting and addressing the factors leading to the poor preconception and infant health impacting client families. Utilizing the Life Course Perspective, the ICP places a strong emphasis on alleviating social factors and life stressors that impact maternal and pregnancy health. An ICP client’s case manager visits from six to nine times over the course of 18 months to stress the importance of nutrition, exercise, sleep, medical conditions, dental problems/infections, and stress on future pregnancies. Case managers conduct assessments of key medical and behavioral/social risk factors, and develop individual care plans with clients. The need to space pregnancies is emphasized and clients are given a $20 gift card incentive every three months for following their reproductive life plan. Clients are given a preconception health kit with items such as dental supplies, vitamins, home pregnancy test, farmer’s market coupons, and educational materials. Case managers also provide referrals and follow-up for dental, wellness, and counseling related to pregnancy risk, and also work to increase stable housing, ensure clients’ other basic needs, talk about healthy partner and parent relationships, and encourage utilization of resources to combat tobacco, alcohol and other drug addictions. Clients also receive home visits from a nutritionist and/or social worker, depending on their individual needs.
Among the positive program outcomes: For the 58 client births subsequent to program enrollment, there was a 998 gram mean birth-weight increase, a 5.1 week mean gestation age increase, and 63% of subsequent births were spaced at least 18 months apart. Only 11% of the infants born to ICP clients during program participation spent time in the neonatal intensive care unit compared to 66% prior to involvement in the ICP. None of the subsequent pregnancies terminated in miscarriages, stillbirths, or infant deaths. While this indicates significant improvement in birth outcomes and program achievement, not all ICP objectives have been met since many subsequent births of clients have not been normal weight or full gestation. It is also more difficult to measure the ICP’s success in improving the factors in clients’ lives—social, physical, emotional, financial—that impact their ability to deliver healthy infants.
Several factors have contributed to the ICP’s success. Having multiple HVP partners with established ICP client relationships involved in case management, and paying them a per client stipend, has allowed the program to grow quickly, though the case management fee will have to be increased in order to sustain the ICP in the future. Working with non-traditional public health partners on health equity, social justice, racial equity, and organizations creating access to transit, healthy food, affordable housing, etc. has allowed the ICP to connect clients to needed services, and ultimately improve their health.
The success of the ICP has significant public health impacts for participants. Pregnancy outcomes are important indicators of child survival and maternal health. They also have a significant impact throughout one’s life. Low birth weight infants are at increased risk of long-term disability and impaired development, and are more likely than normal weight infants to experience delayed motor and social development. Lower birth weight also increases a child’s likelihood of having a school-age learning disability, being enrolled in special education classes, having a lower IQ, and dropping out of high school.
1) KCHD provides services to a population of 606,622 (2010). KCHD is located in Grand Rapids, MI (2010 population 188,040). The percentage of the White and ethnic/racial minority population for Kent County and Grand Rapids, respectively, includes: White: 80%, 65%; African American: 10%, 21%; Hispanic: 10%, 16%; Asian: 2%, 2%. In Kent County in 2010, 15% of individuals and 21% of children under 18 years of age lived below the federal poverty level. For the city of Grand Rapids, these figures were 26% and 38%, respectively.
2) Pregnancy outcomes are important indicators of child survival and maternal health. They also have a significant impact throughout one’s life. Low birth weight (LBW) infants are at increased risk of long-term disability and impaired development, and are more likely than normal weight infants to experience delayed motor and social development. LBW also increases a child’s likelihood of having a school-age learning disability, being enrolled in special education classes, having a lower IQ, and dropping out of high school. Recent studies have also pointed to LBW as a strong predictor of adult health. Children born less than normal weight (>2500 grams) are significantly more likely as adults to suffer hypertension, type II diabetes, coronary heart disease, and have shortened lives.
Kent County agencies have been implementing measures for several years to decrease the local racial disparities in infant health. Under the leadership of the Healthy Kent 2020 (HK 2020) Infant Health Implementation Team (IHIT), Kent County partners have implemented many research-based initiatives and workgroups to address local disparities in infant deaths and birth outcomes. And while the African American infant mortality rate in Kent County has fallen in recent years, to 16.2 infant deaths/1,000 live births in 2008-2011, it remains three times that of the county’s White infants (4.9/1,000). The disparity is even greater in the city of Grand Rapids. The main cause of death is preterm birth (PTB) and LBW. In addition to this devastating loss of life, for every LBW baby that dies there are approximately ten that survive, often with life-long physical, behavioral, and cognitive disabilities.
3) There was a total 2012 enrollment of 1,770 women in the MIHP and Strong Beginnings programs, from which ICP draws nearly all of its clients. Among these enrollees, 40% were African American, 35% White, 23% Hispanic and 4% Asian-Pacific Islander. MIHP and Strong Beginnings do not have data available on the total number of their clients who may be eligible for the ICP. The initial funding for ICP care was intended to reach a minimum of 25 high-risk women annually. The program has far exceeded its targeted caseload, and since inception has enrolled 400 women. Nearly 100 are enrolled annually, or approximately 6% of the HVPs average caseload. There are still a significant number of eligible women not enrolled in ICP due to funding limitations.
4) KCHD has been committed for several decades to HVP interventions that address maternal and infant care among the county’s low-income population. In support of these HVPs (MIHP, Strong Beginnings) and the community’s prenatal care providers, IHIT has worked to address the impacts of maternal-infant health disparities. This has occurred through community engagement regarding local health disparities data and shared personal experiences in venues such as the Summits on Racism Health Care Sector, the Community Summit on Infant Health, and neighborhood meetings. Among the assumptions of this work was that these health disparities emerge from a constellation of socioeconomic and cultural factors, including poverty, racism, and even the operations of the local health care systems. Even after accounting for socio-economic factors and risk behaviors, women of color have higher rates of infant death than their White counterparts. KCHD has confirmed many of these findings at the local level through community focus groups and key informant interviews. IHIT has also engaged stakeholders to increase awareness and discuss systems change, create and disseminate a resource guide for perinatal providers, develop referral pathways to connect women to support services and care. But there was no deliberate means, outside of the HVPs, to carry out enhanced case management for this specific population in need of additional interventions. IHIT was functioning by leveraging in-kind resources of partners to support coalition work. The funds to actually pilot a program based on evidence came from the Michigan Department of Community Health (MDCH). In 2005, MDCH provided funding for health departments in 11 Michigan communities with high infant mortality rates to develop action plans in their communities to reduce these infant mortality disparities.
5) Local MIHP agencies address maternal-infant needs from a framework of physical, nutritional and emotional health. The MDCH-supported infant mortality coalitions considered infant mortality as a social problem with health consequences, exacerbated by poverty, unemployment, unsafe neighborhoods, low education, lack of basic resources, structural racism, and unequal treatment based on the color of one’s skin. IHIT serves as Kent County’s infant mortality coalition. IHIT developed the ICP around these principles and available model practices for interconception care. ICP services are more completely described in ICP clients are recruited and enrolled from among the MIHP clients of KCHD and Cherry Street Health Services, and Spectrum Health’s Strong Beginnings program. ICP case management actually occurs through enhanced MIHP and Strong Beginnings home visits by PHNs who have been equipped with the ICP training and tools. The IHIT Executive Committee serves as the advisory committee for ICP development and evaluation.
Improvements over HVPs for ICP clients also include a wellness component that encourages healthy eating, physical activity and increases women’s access to fresh fruits and vegetables, as research indicates that maternal obesity contributes to poor infant survival and health. Women in the wellness program receive a pedometer and learn to track their daily steps. They are given coupons for purchases at the South East Area Farmer’s Market and recipes that feature in-season market produce. They are encouraged to log their daily fruit and vegetable consumption and to participate in the biometric screenings offered free at the KCHD clinic. ICP clients receive education and encouragement from their case manager as well as an incentive for completing their steps and fruit/vegetable logs. Data on Body Mass Index (BMI) is collected on all ICP clients during enrollment.Many participants in local HVPs lack critical oral health services. Recognizing the role of oral health in healthy pregnancy outcomes and the scarcity of dentists for the publicly-insured and uninsured, KCHD implemented the Brush Up For Baby program (BUFB) for ICP clients. KCHD contracts with the Baxter Holistic Health Center Dental Clinic to provide ICP clients with dental cleanings, periodontal treatment, extractions, restorations and root canals. Clients receive one-on-one attention from a dental hygienist focused on the importance of caring for their teeth and gums.
6) An important innovation incorporated into the ICP tools and protocols is the cultural competency trainings (Creating Inclusive Healthcare Environments) and two-day Health Equity, Social Justice Dialogue (HE/SJ) workshops targeting all PHNs, managers, and community partners involved in the ICP. As a subrecipient to a WK Kellogg Foundation grant to the Ingham County Health Department, KCHD has been able to provide the HE/SJ workshops to all KCHD employees. ICP staff strives to enhance services through the social determinants of health framework, identifying community resources and linking clients to essential needs. Each ICP community partner and PHN case manager receives a Health Equity Toolkit: Framing the Relationship between Race and Health. This resourceful booklet contains information on cultural and linguistic competent care, cultural humility, self, program-level and organizational assessments for gauging practices and biases that discourage health equity, and information on patient rights. http://www.accesskent.com/Health/HealthDepartment/HealthEquity/.
The HE/SJ work is supported by the Responding to Racism Action Team, which was convened by IHIT in 2010 with staff support from KCHD’s Health Education and Promotion (HEP) section. HEP and ICP Supervisor Teresa Branson, and Barb Hawkins-Palmer, Health Kent 2020 and IHIT Executive Director, continually engage in state and national movements to support health equity in public health practice. Ms. Branson and Ms. Hawkins-Palmer have traveled to Minnesota to participate in ISAIAH Leadership Training and The Breakthrough Network for Health Equity.
Innovative ICP services also include addressing the contribution of periodontal disease (PD) to poor birth outcomes, the wellness program’s biometric screenings, completion of a reproductive life plan and staff follow-up on compliance with the plan. Research shows African American women are much more likely to have PD and less likely to have access to dental care than White women. Treating PD may reduce PTB by as much as 10%. Clients receive one-on-one education and frequent monitoring from a dental hygienist focusing on the importance of caring for their teeth and gums. Transportation is provided when needed as well as assistance in finding child care.
6a) The KCHD ICP shares common elements of other models in the Maternal and Child Health section of the NACCHO Model Practices database. The Suffolk County Department of Health Services’ Interconception Care Collaboration is similar to the ICP in that it offers family planning (FP) services. While interconception programming is not a new intervention for local health departments, the KCHD program includes a focus on oral health care for clients, an emphasis on the social factors impacting clients’ health, and HE/SJ as a central framework for program development.
6b.1) KCHD and IHIT and other infant mortality coalitions were prompted by MDCH to utilize local data from the Perinatal Periods of Risk (PPOR) to drive interventions. In Kent County, PPOR data on excess deaths/ infant mortality showed that interventions should target maternal health and prematurity.Local HE/SJ work has been in part modeled after The Community Guide’s Model for Linking the Social Environment to Health, and IHIT also uses the Guidelines for Achieving Health Equity in Public Health Practice to drive their HE/SJ initiatives. This was not the basis for the ICP, but as the program has evolved it has become clear that what is needed is to increase awareness among ICP staff and other IHIT partners of the root causes of health inequities that are contributing to poor birth outcomes.
7) The ICP developed in Kent County is based on two evidenced-based models:
The Interconception Health Promotion Initiative in Denver, and
The Interpregnancy Care Program at Grady Memorial Hospital in Atlanta.
These two programs were recommended by MDCH because of their evidence of positive outcomes and cost savings. The ICP was deemed a state model by MDCH and adopted by six other Michigan counties. All program interventions and protocols are based on evidence that they contribute to improved birth outcomes. Poor nutrition, obesity, chronic disease, substance abuse, domestic violence, mental health issues, unintended pregnancy and racial inequities have all been linked to PTB, LBW, and infant death.
The area’s disparity between African Americans and Whites in the rate of low and very-low/extremely-low weight births is also stark. In 2010, the most recent year for which data is available, 10.5% of Kent County African American infants were LBW compared to 5.4% of White births and 5.3% of Hispanic births. African American infants were also nearly four times as likely to be born very-low or extremely-low weight compared to White and Hispanic infants, and African American infants are 70% more likely to be a PTB than are White infants. Maternal health data for Kent County’s 4,484 Medicaid births in 2009 reveals that 24% of all mothers and 31% of African American mothers had a previous poor birth outcome, 13% of all mothers and 21% of African American mothers used drugs, and 35% of African American mothers reported a history of domestic violence
3)The Interconception Care Program (ICP) targets, but is not limited to, African American women served through the area’s Maternal Infant Health Programs (MIHP) and Strong Beginnings, a Federal Healthy Start program. Women are eligible for ICP services if their last pregnancy resulted in an infant death, fetal demise (after 20 weeks gestation), stillbirth, PTB (before 37 weeks gestation), or LBW, and they have not undergone permanent sterilization. Case managers also consider a women’s socioeconomic risk factors and partner/familial support system in determining their suitability for ICP services.
1)Goal(s) and objectives of practice:
The ICP’s goals are to reduce minority infant mortality, PTB, LBW, increase the number of births with a 12-18 month pregnancy interval, improve oral health, improve maternal wellness, and increase client linkages to community resources related to the social determinants of health.
The specific, measurable objectives to ensure that ICP goals are advanced include the following:
Among ICP clients with a birth subsequent to their program enrollment:
Increase birth spacing to 18 months.
Increase average birth weights to 2,500 grams.
Increase average gestational age of births to 36 weeks.
Complete dental care for 60% of ICP clients including provision of cleanings, periodontal and gingivitis prevention and care, dental x-rays, restorations, and extractions, follow-up visits for education and monitoring. Promote and encourage regular brushing and flossing among clients.
2) What did you do to achieve the goals and objectives? (Please refer to Evaluation section for current program outcomes.)
Increase birth spacing among ICP clients:
Strategies for this objective include:
Case manager assists clients in identifying medical and basic needs and work to build partnerships with agencies to meet client needs.
Promote and encourage ICP clients to enroll to complete and follow a reproductive life plan and/or enroll in family planning services. Provide a quarterly incentive for complying with a reproductive life plan.
Extend recruitment of at-risk women through area hospitals’ neonatal intensive care units.
Increase birth weights and gestational age of clients’ subsequent births.
Strategies for this objective include:
Women in the ICP wellness program receive a pedometer and learn to track their daily steps and to encourage physical activity.
Women receive coupons for purchases at the South East Area Farmer’s Market and recipes that feature market produce.
Assist and encourage clients to log their daily fruit and vegetable consumption, pedometer steps, and to participate in the biometric screenings offered free at the KCHD clinic.
Data on Body Mass Index (BMI) is collected on all ICP clients during enrollment.
Complete dental care to 60% of ICP clients.
Strategies for this objective include:
KCHD contracts with the Baxter Holistic Health Center Dental Clinic to provide ICP clients with dental cleanings, periodontal treatments, extractions, restorations and root canals. Clients receive one-on-one attention from a dental hygienist focused on the importance of caring for their teeth and gums. Prior to receiving BUFB services, 80% of the clients had not been to the dentist in five years, despite having Medicaid dental coverage. Baxter staff document improvement in periodontal disease and gum health by noting changes in tissue color and bleeding on probing. Dental staff also document success in education and client behavior by noting changes in plaque levels, oral hygiene habits, and the patient’s own comments at completion of program.
2a) Steps taken to implement the program In 2005, as one of 11 local infant mortality coalitions, KCHD received a start-up grant of $130,000 from MDCH. The grant funded the development of the coalition, a community action plan to reduce infant mortality, particularly for African Americans, and implementation of evidence-based interconception services. IHIT utilized local Fetal Infant Mortality Review data and PPOR analysis, and obtained community input from key informants and nearly two hundred residents. State funding for ICP ended in 2009 due to budget cuts. The Kent County Board of Commissioners was persuaded with the ICP’s positive outcomes and allocated general fund dollars to continue the ICP. This support will continue at least through the 2014 fiscal year.
3)Any criteria for who was selected to receive the practice (if applicable)? Women are eligible for ICP services if their last pregnancy resulted in an infant death, fetal demise (after 20 weeks gestation), stillbirth, premature delivery (before 37 weeks gestation), or low birth weight birth (less than 2500 grams, or 5.5 pounds) and they have not undergone permanent sterilization. Women with a prior poor pregnancy outcome are 3-4 times more likely to have a subsequent adverse outcome than women with a healthy delivery. The risk of recurrence for PTB is 15% - 30%, and the risk of LBW is anywhere from two to twelve times higher. A pregnancy interval <18 months increases the risk of poor birth outcomes by 30% - 40%,
4)What was the timeframe for the practice The ICP was initiated in 2007 and continues today.
5)Were other stakeholders involved? What was their role in the planning and implementation process? IHIT agencies have been instrumental in assisting the development and providing ongoing direction to the ICP. ICP home visiting services are provided through KCHD’s and Cherry Street Health Services’ MIHP, Strong Beginnings, a federal Healthy Start program of Spectrum Health Hospital utilizing PHN case managers, community health workers (CHW) and a fatherhood coordinator, and Arbor Circle, a provider of infant mental health services to MIHP and Strong Beginnings clients. Other key IHIT agencies include Michigan State University College of Human Medicine (data and research-based practices) and the WK Kellogg Foundation’s maternal-infant health grantee discussion group. 5a)What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) HK 2020 provides the organizational structure for IHIT and its collaborative initiatives. HK 2020 is a collaborative body with an Executive Director, who is an employee of KCHD. HK 2020 has been the most consistent collective response to public health needs in Kent County for more than two decades. It has consistently reached out to and involved more than 30 organizations and community groups to initiate and support projects addressing obesity, violence, substance abuse, suicide, HIV/AIDS, as well as maternal-infant health. Activities and initiatives developed through IHIT are implemented collectively and at the agency level by the various member organizations. IHIT members appoint an Executive Committee, who is responsible for program monitoring, planning, program delivery, and assuring that coalition goals and objectives are met. All planned interventions are brought to the Executive Committee and the full coalition for approval during monthly meetings.
6)Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown. The initial support for the Michigan infant mortality coalitions from MDCH ended in 2009. Current revenue sources include the ongoing Kent County General Fund revenue and external financial support through grants for direct services, as well as a grant for providing HE/SJ training that has positively impacted the program and providers. The total amount of ICP external grant funding was $130,000. Current funding to support ICP services is approximately $184,000 per year.
1)What did you find out? To what extent were your objectives achieved? Please re-state your objectives from the methodology section.The ICP has produced impressive outcomes. Data comparing selected birth outcomes for the clients who have had a birth since enrollment in the program was analyzed in November 2012, and is indicated for the following objectives:
Objective: Increase birth spacing among ICP clients to 18 months by completing ICP case management services to clients through up to 9 home visits by a PHN case manager.
Results: Subsequent birth data was available for 103 clients discharged from the program for various reasons. Fifty percent of these clients had pregnancies subsequent to enrollment. Of those 51 clients, 32, or 63%, were discharged because they had achieved ideal birth spacing of at least 18 months post delivery. These results are very positive considering that 74% entered the program with their most recent pregnancy being unplanned.
Objective: Increase birth weights and gestational age of births to ICP clients. Increasing birth spacing and intervening in women’s lives to improve their pre-pregnancy emotional and physical health should lead to these improved birth outcomes.
Results: Birth weight and gestational age information was available for clients at enrollment and for those giving birth following their ICP participation. There was a statistically significant increase (p<0.05) in mean birth weight from 1,769 grams to 2,767 grams for clients with birth subsequent to program enrollment, and a statistically significant increase (p <0.05) in mean gestational age among ICP clients from 31. 6 weeks during their eligible pregnancy outcome to 36.7 weeks during their subsequent birth.
Objective: Complete dental care for 60% of enrolled ICP clients, including provision of cleanings, periodontal and gingivitis prevention and care, dental x-rays, restorations, and extractions, follow-up visits for education and monitoring. Promote and encourage regular brushing and flossing among clients.
Results: Results are available for 100 ICP clients who have received dental services. Of women enrolled in the program, 73% completed the preventive and treatment portions of the program. There were 148 prophylaxis and education appointments, 269 restorations, 61 extractions, 8 root canals, and 12 early childhood check-ups for 7-24 month old children. Pregnant clients comprised 35% of participants and 34% of clients were in the interconception period. Pregnancy status was not available for the remaining clients.
In 2013, KCHD compared the birth outcomes of a partial cohort of ICP clients who delivered an infant in 2012 after completion of the program with those of a group of women with a previous poor birth outcome who did not participate in the program (control cohort). The analysis of the 2012 births extracted the following variables from the Michigan Birth Registry to evaluate improvements from a previous PTB and/or LBW and a subsequent birth: birth weight, gestational age, number of prenatal care visits and time between pregnancies. Whenever possible, ICP clients were matched to controls on the following variables: year of subsequent birth, age, race or ethnicity, and insurance status (Medicaid vs. private insurance). In order to be used in this analysis, controls were required to have experienced a poor birth outcome immediately prior to their 2012 delivery. This analysis utilized a matched paired t-tests of previous and subsequent births, with a one-to-one match between ICP participants and controls.
While each cohort experienced a statistically significant increase in birth weight from their first to second delivery, there was not an appreciable difference in these results between the two groups. There were also similar increases in gestational age and number of prenatal care visits for both the ICP and control groups. The similarity in results between the two cohorts, however, does not detract from the importance of the results of the ICP participants’ subsequent birth outcomes. Women are selected for ICP enrollment because of birth outcome eligibility but also because their PHN observes other factors in a client’s environment that put them at greater risk of continuing on this trajectory. The ability to draw conclusions from the Birth Registry on the relationship between participation in the ICP and positive subsequent birth outcomes is limited; multiple factors in a woman's life contribute to positive birth outcomes and these factors are not present in all women even though they may share some demographic characteristics. It is a considerable achievement for the ICP clients, given their additional vulnerability to poor pregnancy and infant health, to equal the control cohort in reaching nearly all of the markers of a healthy pregnancy and birth. The analysis of 2012 subsequent births of ICP clients also indicates continued improvement in program goals. The average birth weight in this group was 2,647 grams, the mean gestational age was 35.8 weeks, and the average pregnancy interval was 22.3 months!2) Did you evaluate your practice? KCHD Epidemiology staff assists in analyzing the enrollment data and evaluating data for subsequent birth from the Michigan Birth Registry. ICP and Epidemiology staff also compiled annual reports of program highlights and outcomes for 2009 and 2010. This report is posted on the KCHD web site as well as distributed to IHIT partner agencies. http://www.accesskent.com/Health/Publications/pdfs/KCIHI_2010_AnnualReport.pdf
2a) List any primary data sources, who collected the data, and how (if applicable) Clients’ subsequent birth outcome information is captured from vital birth records. In conducting the analysis of subsequent birth outcomes, KCHD relies solely on variables available in the Michigan Birth Registry (e.g. Medicaid status, number of prenatal care visits, birth weights and gestational age). The Baxter Dental Clinic provided reports on the number and type of dental services provided to ICP clients and the progress in treating periodontal disease, indicating improvement in level of severity at initiation and completion of services. Progress on following a family planning method was monitored by Planned Parenthood of West and Northern Michigan.
2b) List any secondary data sources used (if applicable) 2010 Kent County Fetal Infant Mortality Review; PPOR.
2c) List performance measures used. Include process and outcome measures as appropriate.In addition to the outcomes discussed in the objectives section, decreasing unplanned pregnancies, stillbirth and miscarriages, and admissions of ICP client babies to the Neonatal Intensive Care Unit (NICU) are all important outcome measures monitored in the program. Upon enrolling in ICP, 74% of the women’s previous pregnancies were reported as unplanned, 22% of pregnancies terminated in miscarriages or stillbirths, and 66% of enrollees’ previous infants spent time in a hospital NICU. Data on subsequent births among ICP clients indicates that only 11% of infants were admitted to the NICU. There were no miscarriages or stillbirths in the subsequent cohort. Success in planning pregnancies is evidenced in part by an increased interval between their program eligible birth and subsequent birth. Among subsequent births, 81% were spaced at least 12 months apart and 63% were spaced at least 18 months apart. 2d) Describe how results were analyzed The ICP contracted with Baxter for dental services and Planned Parenthood of West and Northern Michigan for family planning services. These agencies and ICP case managers reported outcome measures for oral health and the follow-up data for the success of clients in following their reproductive life plan, whether that was a contraceptive method or abstinence until a planned pregnancy. Women were also surveyed regarding their experience with Baxter dental services. Pregnancy and prenatal care measures were monitored by the ICP case managers. Data on subsequent births of clients was taken from the county’s birth certificate database. This analysis was carried out by a KCHD Epidemiologist.
All outcomes on subsequent births reported here were analyzed in November 2012. In order to determine whether there were statistically significant changes in birth outcomes among ICP clients with a subsequent birth, a paired t-test analysis was performed using SPSS software. Birth weight and gestational age information was available on both births for 90% of clients.
2e) Were any modifications made to the practice as a result of the data findings? 2000 words
In the first years of the program, ICP referral and enrollment was the role of the MIHP coordinators. They would monitor 12 month chart reviews of their clients to identify and enroll women who had a pregnancy within the past 12 months and also met the eligibility criteria for enrollment. Now, through strengthened partnerships among ICP service providers, the timeliness of identification and enrollment has improved significantly because identification, enrollment, assigning eligible clients to a case manager and support services is a daily component of ICP practice within these HVPs. There has also been increased concentration on family planning services as this is a reoccurring risk factor for many ICP clients, with a clear majority entering the program having had a recent unplanned pregnancy. Modifications are needed in the dental component of the program as the high need for dental care among clients has surpassed the capacity of the ICP’s current provider.
1)Lessons learned in relation to practice KCHD learned from the other ten Michigan counties with infant mortality coalitions that it is absolutely necessary to integrate ICP services into existing HVPs. It is important to have the established infrastructure and relationships, trust, and rapport with the clients that will usually be dually enrolled in the ICP and an HVP. The experience and administrative support of the HVP case manager is key to the ICP success. The ICP continues to grapple with how best to convey the program’s Cost-Benefit/Return On Investment in a way that demonstrates an accurate accounting of the dollars invested, the outcomes attributable to ICP interventions, and the healthcare and social costs associated with poor birth outcomes. At some point, the ICP could benefit from an outside evaluator to collect data to help inform this process and develop program changes based on the information.2)Lessons learned in relation to partner collaboration Partner collaboration is key in promoting the ICP and to help make it sustainable in our community. It will be increasingly important in the future to strengthen the base of ICP supporters, including other local groups working on racial equity. These non-traditional public health partners can create the access to transit, healthy food, affordable housing, employment and job skills that will make improved health during the interconception period and beyond more attainable.
3)Is this practice better than what has been done before? Yes, for several reasons described above.
4) Did you do a cost/benefit analysis? Data specific to Michigan on average expenditures for premature/LBW newborn care comes from the Center for Healthcare Research and Transformation: In 2007, the average charge for a premature birth/low birth weight delivery was $102,000 in Michigan, approximately 14 times higher than the average charge for a normal delivery. And the cost differential continues in the first year of life. Average first year costs for preterm children in 2008/9 for Blue Cross and Blue Shield of Michigan (BCBSM) were $41,700 compared to $4,300 for children born at full term. Children born preterm with BCBSM represented 10.3% of total births but accounted for 52.6% of total spending for all children in the first year of life. (http://www.chrt.org/the-cost-of-prematurity, Nov. 22, 2010.) The subcontracted costs for the ICP total $952 per client. This includes $365 for enrollment/case management, $135 for health items and FP incentives, $75 for wellness program expenses (including farmers' market coupons, blood pressure/ cholesterol screening and incentives); $200 (average per client) for contract dental services (provided by volunteer dentists), and $177 for a comprehensive family planning exam and birth control for 12 months.
The ICP is administered through KCHD’s Health Education and Promotion division. Primary staff responsibilities are managed by a .25 FTE program coordinator. When personnel, administrative and overhead costs are added, the cost per client is approximately $1,740. Considering that the average cost for a PTB/ LBW birth in Michigan exceeds $100,000, with an additional $42,000 in medical costs during the first year of life, the potential cost savings are substantial. Aside from these immediate savings, there are life-long savings from reducing physical and cognitive disabilities, improving academic performance, and preventing chronic disease. Although this RFI addresses financial investments, the added psycho-social and emotional benefits to families and society of having healthy children are immeasurable and should not be ignored.
5)Sustainability – is there sufficient stakeholder commitment to sustain the practice?Supporting sustainability of the ICP is the presence and strength of community partnerships established through IHIT that are committed to addressing African American infant mortality and other racial/ethnic health disparities. This includes the ongoing supportive work of IHIT, the MIHP Provider Network, and the IHIT Responding to Racism Action Team. Another important partner in this work is Strong Beginnings. Strong Beginnings has teams of community health workers, nurses, and social workers who recruit and engage high-risk mothers. The goals of the ICP are also shared by community partners of the Kent County Working Together for a Healthy Tomorrow Coalition’s Community Health Improvement Plan (CHIP). Among the CHIP objectives of the work plan, to be completed by 2015, are:
Increasing by 10% the proportion of pregnancies that are intended;
Increasing community awareness and perceived importance of early and adequate prenatal care by 10%, and;
Reducing by 5% the disparity between African American and white women in Kent County in adequacy of prenatal care.
5a) Describe sustainability plans 1500 words
There has been a strong institutional commitment to providing ICP services for eligible women. In 2000, KCHD designated reducing African American infant mortality as a priority department goal. Since then, Kent County has allocated General Fund revenue to help sustain ICP services for KCHD clients. ICP staff and KCHD administration have also been successful in obtaining grant funding for the program from three different agencies. The funding has allowed the program to expand in number as well as increase the breadth of services offered.
The underlying goal of the ICP is to integrate ICP protocols as a standard of care in HVPs for women during periods of interconception. As a greater number of KCHD and other agencies’ HVPs participate in the ICP, ICP protocols will increasingly be adopted for all HVP clients, thereby ensuring women receive enhanced services and increased likelihood of optimal preconception health. This KCHD organizational commitment will eventually lead to the routinization of the ICP’s most important services among KCHD maternal-infant health programs. This entails development of MIHP program policies that lead to routine MIHP assessment and referral to support services for risk factors associated with poor pregnancy outcomes. The Kent County MIHP Provider Network will also continue to advocate at the state level for integration of ICP in the state’s redesign of MIHP.Program sustainability will also be bolstered through effective monitoring and evaluation of the ICP to produce favorable results. KCHD’s Epidemiology staff will provide necessary support for program evaluation. By demonstrating program effectiveness through subsequent healthy birth outcomes, and data to support program benefits that justify program costs, the likelihood of securing other ICP funding will be enhanced.
Thus far, KCHD has observed compelling evidence to continue to fund ICP interventions. In fact, KCHD is the sole agency among the 11 originally supported by MDCH in 2005 to maintain an ICP. Hopefully, these results will also continue to compel public and private funders to continue outside support for these services.