What about Mom?

State: FL Type: Model Practice Year: 2008

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The goal of this program is to lower the overall Pinellas IMR and VLBW/LBW rates by providing free ICC services to high-risk new mothers in the unique setting of a pediatrician’s office (St. Petersburg Pediatrics), during regular "well baby" check-up visits. The program addresses findings from the most recent Periods of Perinatal Risk Report (PPOR) that indicate the need to reach women prior to pregnancy and improve access to care.

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Pinellas County Health Department
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What about Mom?
The goal of this program is to lower the overall Pinellas IMR and VLBW/LBW rates by providing free ICC services to high-risk new mothers in the unique setting of a pediatrician’s office (St. Petersburg Pediatrics), during regular "well baby" check-up visits. The program addresses findings from the most recent Periods of Perinatal Risk Report (PPOR) that indicate the need to reach women prior to pregnancy and improve access to care.
The public health problem addressed by the ongoing What About Mom? program is Infant Mortality/Morbidity in Pinellas County, Florida. In 2006, African American infants in Pinellas County were about four times more likely to die before their first birthday than Whites (W: 5.6; B: 24.3) and three times more likely to be born at a very low birth weight (VLBW). These data are from the Community Health Assessment Resource Tool Set (CHARTS) compiled by the Florida Department of Health, Office of Planning, Evaluation and Data Analysis. The most effective way to reduce infant mortality (IMR) is to prevent LBW babies. The best way to reduce the number of VLBW/LBW babies is to have a healthy mother at conception. The cause for VLBW/LBW babies is rooted in both medical and socioeconomic risk factors in and around the program target area of four contiguous zip codes (33705, 33711, 33712, and 33713) in south Pinellas--home to the county’s largest population of African Americans and including approximately 12,000 African American women of childbearing age. Risk factors include late prenatal care, teen births, anemia during pregnancy, overweight and obesity, unwanted pregnancies--factors disproportionately present in the Black population. Local data from the Behavioral Risk Factor Surveillance System (BRFSS) paint a disturbing picture of the program’s target area: In 2003, more than 10 in 100 Black women were anemic during pregnancy compared to less than 3 per 100 Whites. Almost half of Black pregnant women were overweight or obese compared to just over one-third of Whites. Almost 6% experienced violence in the home, and over 16% described themselves as being under high stress during pregnancy. These high-risk women are burdened by myriad public health problems associated with urban poverty and a vulnerable population: violence, crime, unemployment, inadequate housing, substance abuse, and mental health issues. The health disparities in infant mortality, perinatal health, interconceptional health, and management of chronic health conditions experienced by African American women create the need for non-traditional interventions to reach these women. For most women, the healthcare system stops in adolescence and begins again when the woman becomes pregnant. The Saint Petersburg Healthy Start Federal Project has designed an innovative community-based program, What About Mom?, a public/private partnership that provides interconceptional care to women during routine well-baby visits. The benefits of providing community-based nursing services in the office of a private practitioner are (1) reducing barriers for clients with limited time and/or transportation; (2) providing immediate intervention and services to address/manage chronic illnesses; and (3) offering community resource information to uninsured/underinsured clients. Saint Petersburg Pediatrics, a multi-office practice, is popular among the African American community, and is the largest Medicaid provider examining all Medicaid or unassigned (no insurance/no provider) newborns in south Pinellas County. Through a partnership with Saint Petersburg Pediatrics, a senior community health nurse provides interconceptional mothers with health information and minor medical services including but not limited to blood pressure checks, family planning, birth control, and pregnancy testing.
Agency Community RolesMuch of the success of What About Mom? can be attributed to St. Petersburg Pediatrics, one of the area’s top pediatric Medicaid providers. As a community partner, St. Petersburg Pediatrics provides in-kind office space. Additionally, it is integral to the referral process. The staff of St. Petersburg Pediatrics addresses vital interconceptional care issues on a daily basis. As soon as the baby is born, often all the attention is focused on the baby's health, whilst the status of the mother's health remains unaddressed. St. Petersburg Pediatrics is popular in the African American community, and the mothers were thrilled with the convenience of receiving services at the pediatrician's office. This service allows for fewer missed hours from work and alleviates the stress of transportation issues for these women. Like the Pinellas County Health Department, St. Petersburg Pediatrics believes that a healthy baby begins before pregnancy with the good health of the mother. Therefore St. Petersburg Pediatrics was happy to partner with the health department in this endeavor to bring education and medical care to the often forgotten new mother. The Senior Community Health Nurse in the program is employed by the Pinellas County Health Department and is an experienced triage/family planning nurse and a certified STD/HIV counselor. Costs and ExpendituresThe program costs include: Nurse’s salary: $56,000. Pharmaceutical inventory (e.g., birth control pills, Depo-Provera, pregnancy tests, prenatal vitamins, folic acid supplements): $12,000. Off-site network access: $550. Office space: provided in-kind. ImplementationA partnership was initiated between the Pinellas County Health Department and the St. Petersburg Pediatric clinic, operationalizing the concept of a medical home. The St. Petersberg Pediatrics is a multi-office-practice Medicaid provider that sees Medicaid or unassigned newborn infants. It is also a practice frequented by the African American community in St. Petersburg. A public health nurse from the Pinellas County Health Department was stationed at St. Petersburg Pediatric in September 2005 after collaborative meetings with the primary owners and operators of the practice. The nurse was set up in a separate office space. A client filing system and triage log were developed. An off-site pharmacy was established and inventory maintained. The program services were marketed and promoted. Referrals to the program are received from providers (referring new patients) and self referrals. Clients are triaged and provided services based on their assessments. Community referrals are provided as needed. St. Petersburg Pediatrics also agreed to new-mothers information about the What About Mom? program on their first contact with the doctor before discharge from the hospital. In the office at the conclusion of the well-baby visit, for all new mothers, the physician will offer What About Mom? services to the mothers and direct them to the nurse's office. The nurse will evaluate and assess each mother. The Women's Health Questionnaire and the Edinburgh Depression Scale are two tools used to assess the mothers' risk factors. After determining clients' needs, the nurse provides the clients with health information, referrals, and minor medical services, including but not limited to blood pressure screening, family planning, birth control, pregnancy testing, HIV/STD prevention counseling and testing, referral for primary care, mental health care, and community resources. Much of the success of What About Mom? can be attributed to St. Petersburg Pediatrics, one of the area’s top pediatric Medicaid providers. As a community partner, St. Petersburg Pediatrics provides in-kind office space. Additionally, it is integral to the referral process. The staff of St. Petersburg Pediatrics addresses vital interconceptional care issues on a daily basis. As soon as the baby is born, often all the attention is focused on the baby's health, whilst the status of the mother's health remains unaddressed. St. Petersburg Pediatrics is popular in the African American community, and the mothers were thrilled with the convenience of receiving services at the pediatrician's office. This service allows for fewer missed hours from work and alleviates the stress of transportation issues for these women. Like the Pinellas County Health Department, St. Petersburg Pediatrics believes that a healthy baby begins before pregnancy with the good health of the mother. Therefore St. Petersburg Pediatrics was happy to partner with the health department in this endeavor to bring education and medical care to the often forgotten new mother. The Senior Community Health Nurse in the program is employed by the Pinellas County Health Department and is an experienced triage/family planning nurse and a certified STD/HIV counselor. Costs and ExpendituresThe program costs include: Nurse’s salary: $56,000. Pharmaceutical inventory (e.g., birth control pills, Depo-Provera, pregnancy tests, prenatal vitamins, folic acid supplements): $12,000. Off-site network access: $550. Office space: provided in-kind. ImplementationA partnership was initiated between the Pinellas County Health Department and the St. Petersburg Pediatric clinic, operationalizing the concept of a medical home. The St. Petersberg Pediatrics is a multi-office-practice Medicaid provider that sees Medicaid or unassigned newborn infants. It is also a practice frequented by the African American community in St. Petersburg. A public health nurse from the Pinellas County Health Department was stationed at St. Petersburg Pediatric in September 2005 after collaborative meetings with the primary owners and operators of the practice. The nurse was set up in a separate office space. A client filing system and triage log were developed. An off-site pharmacy was established and inventory maintained. The program services were marketed and promoted. Referrals to the program are received from providers (referring new patients) and self referrals. Clients are triaged and provided services based on their assessments. Community referrals are provided as needed. St. Petersburg Pediatrics also agreed to new-mothers information about the What About Mom? program on their first contact with the doctor before discharge from the hospital. In the office at the conclusion of the well-baby visit, for all new mothers, the physician will offer What About Mom? services to the mothers and direct them to the nurse's office. The nurse will evaluate and assess each mother. The Women's Health Questionnaire and the Edinburgh Depression Scale are two tools used to assess the mothers' risk factors. After determining clients' needs, the nurse provides the clients with health information, referrals, and minor medical services, including but not limited to blood pressure screening, family planning, birth control, pregnancy testing, HIV/STD prevention counseling and testing, referral for primary care, mental health care, and community resources.
The outcomes of the practice can be described in terms of (a)benefits for the clients and (b) benefits for the provider(s). Benefits for the clients: -Reduction in barriers to accessing healthcare -Provision of immediate medical intervention if needed -Promotion of BOTH physical and mental wellness -Provision of a "medical home" by the provider(s) Benefits for the provider(s): -Assist in providing continuity of care -Promotion of a family-centered approach to healthcare -Reinforcement of the physician's recommendations -Provide follow-up services -Provision of a "medical home" for the clients
What About Mom? is a component of the four-year St. Petersburg Healthy Start Federal Project, funded through May of 2009. The St. Petersburg Healthy Start Federal Project comes under the umbrella of the Pinellas Healthy Start and is funded by the U.S. Department of Health and Human Services, Health Resource and Services Administration. As a standalone pilot component of the federal Healthy Start project, What About Mom? can be successfully replicated in any state or area where a willing pediatrician can be recruited to provide space and support for the program. The success of the current program can be used as a convincing selling point for private clinics to participate.
 
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