An In Infant Feeding Toolkit for Home Vis isitors Elaine L. Fitzgerald, DrPH, MIA, CLC Dominique Bellegarde, BHSI Case Manager, CLC
Objectives • Introduce Infant Feeding Toolkit • Why Boston Healthy Start identified the need • How the toolkit was developed • What the toolkit includes • Integrate the Infant Feeding Toolkit into Your LIA • Using Quality Improvement PDSA Cycles • Collaborative Learning • Ideas for Improvement
Key Driver Diagram: HV CoIIN Breastfeeding Specific Ideas to Test Secondary Drivers or Change Concepts Use of standardized infant Primary Drivers July PDSA Report Feeding plan 1. Breastfeeding policy, protocol and print resources for the Protocol for HV delivery of BF support (i.e. -CF, delivery of breastfeeding support prenatally and postnatally Boston Infant Feeding Toolkit ) -Calhoun, childrens friend (infant feed plan), Kenosha * Some LIAs are working across 1. Standardize Use of new resources to Protocols for documenting communication and 2. Standardized professional development for home visitors educate mothers from NFP-- more than 1 driver, therefore the internal (agency) referral of families to key community partners -Calhoun in breastfeeding policies and protocols total number of LIAs represented policies and practices Initial and refresher training for HVs on agency 1. Home visitors with lactation and breastfeeding knowledge is larger than 11 to support polices and protocols- Kenosha (NFP forms) & competencies breastfeeding Print materials align with CDC Guidelines -Calhoun 2. Regular professional development for home visitors on infant feeding practices that support a culturally sensitive, -Childrens Friend (CF) Competencies for HVs to adequately address family centered, relationship-based approach- Pike -Kenosha breastfeeding with families 3 3. Regular access to performance data for quality improvement Requirement and provision of training for home visitors consistent with United States 4. Timely and effective supervisory support 2. Build capacity of Breastfeeding Committee guidelines and support for 1. Establish cooperative relationships with key community Data on measures provided regularly to home home visitors to breastfeeding partners (WIC, La Leche League, etc.) SMART Aim visitors to use in quality improvement - Pike, Western Tidewater, Eastbay, NE Florida address to increase by 20% Regular Reflective supervision breastfeeding in the from baseline the % 2. Establish relationships with breastfeeding support groups target populatio of women exclusively Memorandum Of Understanding with Key Establish relationships and linkages with medical and 1 -Pike Community Partners (i.e. WIC) Work to Build New BF policy breastfeeding at 3 educational field, e.g. hospitals, primary care, obstetrical in schools – NE FLorida providers, schools- NE Florida months & 6 months Current resource list of peer support groups and 3. Create strong Baby-Friendly hospitals (DETROIT- list of WIC 3. Close loop of communication for referral, access and Outcome measure: community linkages offices) engagement in breastfeeding supports and services Establish breastfeeding teams- Eastbay, NE Fl (in home) to breastfeeding % of women who 1. Mothers informed of the benefits of breastfeeding (paying support systems Protocol for warm hand off and follow-up report exclusive BF at special attention to debunk myths) Calhoun, Meeting street - Pike 3 & 6 months Use of Boston Healthy Start Infant Feeding Toolkit-Family -Western Tidewater Resources 2. Mothers empowered to meet individual BF goals (ind BF -Eastbay Use of standardized infant Home Visitors utilize Best Start 3- Step Counseling strategies plans) -NE Florida Feeding plan CF, Meeting Street, Eastbay, Family Resources, 5 -CF, Meeting street, -Detroit Home visitors use practices/resources that help to identify Clark County and strengthen formal and informal supports (partner, Clark,Family Resources, (plus goodie bag) 4. Family Engagement other family members, etc.)- Meeting street, Resource list 3. HV engages in regular client-led conversation regarding breastfeeding - Calhoun, Meeting Street Home Visitors utilize practices from Secrets of Baby *The above Plus joint WIC Behavior curricula -Childrens friend, Family Resources visit (PD3) 6 4. Use of best practice/evidence-informed strategies to -Eastbay -Eastbay, Clark Breastfeeding print resources for families that align with the enhance mother-infant breastfeeding practices CDC Guide to BF Intervent ion – Calhoun from NFP
National Breastfeeding Rates GAP GAP Source: National Immunization Survey (2004 – 2008)
Breastfeeding Strategies CDC recommends: • Comprehensive clinical and social supports • Pregnancy postpartum period Effective Strategies: Baby Friendly Hospital Initiative Peer Counselors
Critical Periods in Breastfeeding Behavior Time Period Outcome Intention to Breastfeed Prior to Delivery Increase likelihood of successfully breastfeeding Skin to Skin Contact Within 1 hour postpartum Increase duration of exclusive breastfeeding Initiating breastfeeding Within 24-48 hours Reduce likelihood to not introduce supplements Continued breastfeeding 2 weeks postpartum Build confidence and self-efficacy
Supportive Environment • Community-based and Perinatal case management in-home supports and • Continuum of services (prenatal postpartum) Home visiting programs • Reflect language and culture of the community served
Boston Healthy Start Initiative (BHSI) - 2011 Self- Report Participant Demographics (n=1206) Black or African American 100% Latina or Hispanic 34% Age Range 15 – 45 Single 53% < H.S. Education 37% Unemployed 62%
Themes from BHSI Case Manager Focus Groups February – March 2011 1. No standardized training, policies, or protocols: • Breastfeeding • How to promote breastfeeding • How to support clients to breastfeed 2. No tools or references available to communicate consistent and accurate information on breastfeeding 3. Lack of confidence to promote breastfeeding or communicate the benefits of breastfeeding 4. Confusion about community supports and resources available to nursing mothers
Barriers to Breastfeeding among BHSI Clients Enrollment period: July 1, 2010 – June 30, 2011 Difficulty Initiating and Sustaining 71% of women indicating intent to breastfeed were not breastfeeding as recommended Behavior Insufficient Milk Supply Leading reason BHSI clients report for not breastfeeding exclusively Low Literacy Levels 40% of BHSI clients < high school education 30 different nationalities represented Significant portion have limited English verbal and written skills Difficulty communicating with providers Difficulty navigating health care systems
BHSI Breastfeeding Data Summary • BHSI breastfeeding initiation rate (72%) < Healthy People 2020 goals (89%) • Majority of BHSI clients who initiate breastfeeding supplement partially or exclusively (64%) increasing likelihood of premature weaning • Majority of BHSI clients (71%) intending to breastfeed face difficulty sustaining • Data limitations • Unable to analyze when formula was introduced, how long child was exclusively breastfeed • Missing / erroneously entered data • Insufficient data collected on breastfeeding concerns / issues
Approach Aim : Improve perinatal case management services by building case manager capacity to promote breastfeeding & support nursing clients Method : Quality Improvement (PDSA Cycles)
Quality Improvement Methodology Learning Collaboratives : • Systematic way to test & disseminate new knowledge and innovation • Function through a structured process • Bring diversity of providers together to improve the quality of a specific aspect of their service or program • Aim to close the gap between research and practice using PDSA process • Purpose - serve as the working body to operationalize QI activities
BHSI Infant Feeding Learning Collaborative BHIS - IFLC Purpose: Working body to move through QI activities using PDSA cycles Structured: Weekly / Biweekly meetings Members: • BHSI Administrators • BHSI Case managers & Site supervisors • BPHC Evaluator • Representative of Healthy Baby Healthy Child • Community Stakeholders (clients, lactation consultants, physicians) • MCH doctoral candidate
AIM To improve perinatal case management services by building case manager capacity to promote breastfeeding & support nursing clients *Developed by BHSI Infant Feeding Learning Collaborative
Change Concepts Aim : Improve perinatal case management services by building case manager capacity to promote breastfeeding & support nursing clients • Changing the work environment • Enhancing relationships between home visitor and client • Managing variation
Change the work environment • Train home visitors on recommended infant feeding practices and basic counseling skills • Develop cooperative relationships with key community partners
Enhance client relations Improve home visitors capacity to: • Listen effectively • Support clients to develop self-advocating skills • Support clients to meet individual breastfeeding goals
Manage variation • Standardized infant feeding training • Infant Feeding Toolkit to guide interactions
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