SU SUPP PPORT RT FOR TWO GENE NERAT ATION ION PR PRIM IMARY - - PowerPoint PPT Presentation

BUI UILDIN ING CAP APAC ACIT ITY Y AN AND SU SUPP PPORT RT FOR TWO GENE NERAT ATION ION PR PRIM IMARY ARY CAR ARE

Colleen Kraft, M.D., FAAP Medical Director, Health Network by Cincinnati Children’s

Learning Objectives

• Consider new models of primary care that

prevent toxic stress and build the health of parents and children;

• Recognize new financing models that

promote two generation primary care;

• Discuss ways maternal/child health

professionals might advocate in translating science into healthier life- courses

Significant Adversity Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments Healthy Developmental Trajectory Impaired Health and Development

Current Conceptual Framework Guiding Early Childhood Policy and Practice

Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status

Adverse Childhood Experiences

Social, Emotional, and Cognitive Impairment Adoption of Health-Risk Behaviors Disease & Disability

Early Death

Death Birth

The True Nature of Preventive Medicine

Slide modified from V. J. Felitti

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Advances in Developmental Science

Li Life-Cour Course se Sc Scie ience nce Epig pigene netics tics De Developm lopmental ental Ne Neuroscience

• science

Eco-Bio-Developmental Model of Human Health and Disease

Biology

Physiologic Adaptations and Disruptions

Life Course Science

The Basic Science of Pediatrics

Eco cology

• gy

Becomes biology logy, And together they drive development lopment across the lifespan

Translation and Advocacy

The Science cience of

• f

Ea Early ly Brai ain n an and Child ild Development elopment

Epigenetics Physiology of Stress Neuroscience Education Health Economics

On One Science cience – Man any Im Implications plications

The critical challenge now is to tr tran anslat slate game-changing advances in development

• pmental

al sci cien ence ce into effective policies cies and pra ract ctices ices for families w/ children to improve educa cati tion

• n, health

th and lifelong long pro roductiv ctivit ity

PREVENTION OF ACES STARTS AT -9 MONTHS!

Critical Concept #1

Impact of Early Stress

TOXI XIC STRESS

brain expression

• f the GC receptor

MATERNAL STRESS

methylation of the FETAL glucocorticoid (GC) receptor gene NEWBORN HPA reactivity and salivary cortisol levels

Carilion Clinic-Aetna Partnership

10 Carilion Clinic

ACO

Carilion Clinic Physicians Private Practice Physicians

Virginia Medicaid Regions

Maternal-Child Triple Aim

Prevention of Adult Disease Optimize Health and Development

Reduce High

Cost Care

Care Management Design

• Home Visiting Contract
• “High Touch”, in-person, in-home

– Prenatal – Early Childhood – Asthma Case Management – Behavioral Health Case Management – Oral Health Screening/Dental Varnish

Home Visiting Intervention Pilot

Home Visiting = In-Home Prenatal Care Management

IDEA

• Poverty is a risk factor for

poor maternal and newborn

• utcomes.
• What if every mother with

Medicaid had a Home Visitor to provide support, education, transportation?

• How would this impact

health of the next generation? AIM STATEMENT

• Reduce the number of

infants born at <37 weeks gestation and low birth weight (<2500 grams) by 30% by December 2012 utilizing home visitors as in-home case managers.

Driver Diagram

Access to prenatal care Health insurance Transportation Access to behavioral health Emotional support Healthy nutrition Smoking Cessation Reduced numbers of premature and low birth weight infants Improved maternal physical and behavioral health Reduced cost of care (due to reduced NICU days) Outcomes Primary Drivers RELATIONSHIP

Emotional support, healthy nutrition, smoking cessation, parenting readiness, pregnancy health and when to call

SYSTEMS

Screening and enrollment for health insurance, In home data collection

CONNECTION

Home Visitors connect with pregnant moms; incentives; depression screening, referral , treatment

Secondary Drivers

Team Huddles, CQI

National Benchmark=March of Dimes

Virginia

• “C” grade for premature

birth

• Total prematurity = 11.3%
• Late preterm (34-36 wk)

= 8%

• Uninsured = 17.2%
• Maternal smoking =

15.2% Roanoke/Allegheny

• Metrics worse for this

region

• Prematurity = 12.2%
• Late preterm (34-36 wk)

= 10.1%

• Uninsured =15.6%
• Maternal smoking =

24.4%

Measures

Measure

Health Care Cost

Percent of infants born at > 37 weeks gestation

O

Percent of infants born between 34 and 36 weeks gestation (late preterm)

O

Birth weight Percent of infants <2500 grams

O

Percent of Pregnant Moms participants who smoke that stopped smoking

O

Percent of Pregnant Moms participants who start prenatal care in the first trimester

P

Percent of Pregnant Moms participants who attend all the recommended prenatal visits

P

Percent of Pregnant Moms participants who are uninsured

P

Percent of Pregnant Moms participants identified with depression

P

Percent of Pregnant Moms participants connected to treatment for depression

P

Cost of Care

C

1st Trimester—Goal =90%

Percent Goal = 90%

All Visits-Goal = 60%

Percent Goal = 60%

Reduce Maternal Smoking by 1/3

Percent Goal = 16%

Perinatal Depression

Reduce Percentage of Infants born <37 weeks by 30%

<37wk 34-36 wk Goal

Reduce Percentage of Term Infants born < 2500g by 30%

Cost of Care

Note: One premature infant March 19-May 10

Theory on Preventing Prematurity

Seek Population Health Through Place Based Care Design for Sustained, Empathic Care Build Seamless Community Connections

The Challenge

UCMC

University Hospital

Prenatal2

PPC

Prenatal3

Pediatrics2

Good Samaritan

Good Samaritan Hospital

Pediatrics3

Prenatal5 Prenatal6

Home visiting, Community health workers

Housing, partner violence, legal assistance, food assistance, mental health svcs

Community

ER

UCMC

University Hospital

Prenatal2

PPC

Prenatal3

Pediatrics2

Good Samaritan

Good Samaritan Hospital

Pediatrics3

Prenatal5 Prenatal6

Home visiting, Community health workers

Housing, partner violence, legal assistance, food assistance, mental health svcs

Community

ER

Early, sustained, valued, evidence based prenatal care for every mom Activated mothers supported by engaged communities Early, valued, accessible, coordinated care in the community Timely valued services that reduce hardships Early, valued, expert, accessible medical home for every child

UCMC

University Hospital

Prenatal2

PPC

Prenatal3

Pediatrics2

Good Samaritan

Good Samaritan Hospital

Pediatrics3

Prenatal5 Prenatal6

Home visiting, Community health workers

Housing, partner violence, legal assistance, food assistance, mental health svcs

Community

E R

Early, sustained, valued, evidence based care for every mom Activated mothers supported by engaged communities Early, valued, accessible, coordinated care in the community Timely valued services that reduce hardships

90% by 12 weeks 90% by 15 weeks 90% by 18 weeks 80% by 7 days 85% after ≥weeks 90% by 15 weeks 30% reduction

Early, valued, expert, accessible medical home for every child

UCMC

University Hospital

Prenatal2

PPC

Prenatal3

Pediatrics2

Good Samaritan

Good Samaritan Hospital

Pediatrics3

Prenatal5 Prenatal6

Home visiting, Community health workers

Housing, partner violence, legal assistance, food assistance, mental health svcs

Community

E R

Early, sustained, valued, evidence based care for every mom Activated mothers supported by engaged communities Early, valued, accessible, coordinated care in the community Timely valued services that reduce hardships

Early: SDA, community fora, MOUs Sustained: call backs, scheduling Valued: comm aware, feast, family centered, what matters to me, empathy training Evidence: OB bundle Every: zip code, registry Activated: contingency planning, what matters to me Engaged: video, educational fora, messaging, MOU’s, mentors Early: phone referrals, lean processing Accessible: Coordinated: 2 way consent, huddles Timely: personal intake relationships; contingency planning Valued: referrer has deep knowledge of service available 90% by 12 weeks 90% by 15 weeks 90% by 18 weeks 80% by 7 days 85% after ≥weeks 90% by 15 weeks

Early, valued, expert, accessible medical home for every child

30% reduction Early: outreach, rescheduling, Valued: comm knowledge, Expert: anticipatory advice Accessible: walk in appts

SCREENING FOR TOXIC STRESS BELONGS IN THE MEDICAL HOME

Critical Concept #2

Primary Care Innovation to Address Toxic Stress

• Comprehensive approach to screening for

hardships

• Community system of partnerships
• Home Visiting integrated with the Medical Home

DRAFT

What A Well-Trained Clinic Will Detect Maslow’s Hierarchy of Needs

Hunger; homelessness; denial

• r delay of benefits;

utility shut offs Domestic violence; mental health issues; inadequate education services Overwhelmed new parents; lack of parenting role models Unemployment; lack

• f high school degree;

ex-offender reentry issues

Potential Collaborations

Achieving potential Esteem & Respect Belonging Safety Basic Human Needs

• A. Henize (2013)

Using EMR to drive social history screening

Benefits Housing Depression Domestic Violence All others

5 10 15 20 25 30 35 40

May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 # of referrals/1000 Well Child Visits

Child HeLP Referrals per 1000 Well Child Visits

PPC Fairfield Hopple

Connecting to Community Services

KIND (%) No KIND (%) P Lead complete 81 75 <.01 ASQ complete 27 20 <.01 ≥5 well visits in first 14 months 42 29 <.01 Social risks identified Food insecurity 57 10 <.01 Parental depression 11 5 <.01 Housing issues 15 6 <.01 Benefit issues 24 14 <.01 Domestic violence issues 5 2 <.01 Referrals to social work 29 18 <.01 Referrals to MLP 15 6 <.01

Preventive services use among children receiving free formula (KIND) vs. who did not (Klein)

Family-Centered Medical Home

Child and Family

Developmental Services Home-visiting network Early Intervention Child Care Resource & Referral Agency Early HeadStart & HeadStart Early Child Mental Health Services

Prevention, Building Health Acute Care Chronic Care Developmental Services

Parenting Support Lactation Support

Vulnerable children and families Medically Complex Children

Medical Home: Pediatric “Extensive” Care

Child and Family

Shared In- basket with EHR Health Concierge Screening, risk id Medical or social needs, refer to CHIP

CYSHCN, refer to CCC , Special Families Anticipatory Guidance reinforced in-home

Oral Health Ed, Fluoride, dev scr

Home Visiting Partners for Higher Risk Families

• Child Health

Investment Partnership of the Roanoke Valley

• Home Visiting with a

Health Focus

– Parents As Teachers – Oral Health – Asthma Management – Pregnant Moms – Behavioral Health

Who are the Home Visitors?

• Team Care

– Each team has one RN – Three “family intervention specialists”

• AAS trained
• Trained in Evidence-based model (Parents As

Teachers)

• Often from community being served

40

Care Management Design

• Home Visiting Contract

– Paid per member/per month

• “High Touch”, in-person, in-home
• Data Collected in home

– HEDIS metrics – Health Outcomes – Reduced costs

Early Childhood support/guidance

• Parents as Teachers

– Parent/Child curriculum – Frequent Developmental Screening

• Safety

– Sleeping – Car seats – Home safety

• Anticipatory Guidance

– Relevance in home setting

Oral Health and Fluoride Varnish

• Begin with a Grin!

Behavioral Health

• Prenatal to age 7
• Perinatal/postpartum

depression screening

• Connection to

services for parents and children at-risk and diagnosed

• Transportation to

visits

Results

100% families receive early childhood education 90% 2yr olds UTD on well visits and immunizations 100% children are screened for lead, Hgb, development 97% children have a Dental Home 66% of children have had a dental visit by age 3 97% have had an oral health assessment and fluoride varnish

NURTURING SETTINGS FOR YOUNG CHILDREN CREATE A HEALTHY ENVIRONMENT FOR DEVELOPING BRAINS

Critical Concept #3

Early Experiences are Crucial

• By age 3, 80% of

synaptic connections are already made

• By the second

decade of life growth levels off and pruning begins

• Increased

experiences define the wiring of an infant’s brain

Two Types of Plasticity

• Sy

Synapti aptic c Plast astic icit ity –

– Variation in the STRENGTH of individual connections – Development of long term and working memory – Dysfunction results in working memory deficits

• Cellul

ular ar Plas astic ticity ty –

– Variations in the NUMBER (or COUNT) of connections – Billions of connections made, many redundant – “Pruning” of connections after age 5-6

49

Human Brain at Birth 6 Years Old 14 Years Old

Brain Stem & Cranial Nerves: Vital functions Swallowing Cerebellum: Smooth movements Coordination Occipital Lobe: Visual processing Parietal Lobe: Integration of sensory data and movement Temporal lobe (outside): Processing sound and language Limbic System (inside): Emotions and impulsivity Frontal lobes: Abstract thought, reasoning, judgment, planning, impulse and affect regulation, consequences

Brain ain St Structure ructure (and and Fun unction) ction)

+ The Gas Pedal al + Amygd gdal ala

• The Brake

e – PFC C (with some hippocampal help)

Partners for Healthy Environments

Home Visiting Quality Child Care Head Start/ Early HS

High Quality Pre- School

Parent- child play and support

Early Head Start-Child Care Partnerships

53

Provide Head Start grantee requirements for:

• Eligibility, recruitment, selection, attendance
• Early childhood education and development
• Health and safety
• Health promotion
• Nutrition
• Disabilities
• Parent involvement
• Family partnerships
• Community partnerships
• Administrative and financial management
• Transportation and facilities

Head Start Performance Standards

Promoting the Five R’s of Early Childhood Education

• READIN

DING together - daily

• RHY

HYMING ING, playing and cuddling

• ROUT

UTINES NES – help children know what to expect of us - what is expected of them

• REWARDS

ARDS for everyday successes – PRAISE is a powerful reward

• RELA

LATIONS TIONSHIPS HIPS, reciprocal and nurturing – foundation of healthy child development

Yin/Yang of Early Childhood:

• PROTECT

TECT the Brain

• BUI

UILD LD New Skills

Protect the Brain Build New Skills

Toxic Stress Maladaptive Skills SE Buffers Adaptive Skills

HEALTH = EDUCATION, NUTRITION, EMPLOYMENT, BEHAVIOR—FUND IT THAT WAY!

Critical Concept #4

El Paso, Texas

School is the “hub” for two generation care

• School is the location for:

– Pediatric care – Obstetric care – Family primary care

• Weekly dinners and family engagement

– Dinners attended by approximately 400 families/week – Education or Health topic

Services That Support Health

• Computer repair

– Offered to all parents – They can buy computers for $25

• Broadband access

– Within 14 miles of school

• Spanish to English tests

– Weekly drawing for $100 for those who complete tests

HEALTH = EDUCATION, NUTRITION, EMPLOYMENT, BEHAVIOR—FUND IT THAT WAY!—PART 2

Critical Concept #5

Where is Payment Reform in Health Reform?

Direction payers are heading

Health Network by Cincinnati Children’s Partnership with Medicaid

Fee for Service Payments

HNCC Network providers CCHMC Employed Physicians

Cincinnati Children’s Hospital Variable Capitation

HNCC Network

State of Ohio ODJFS Utilization Mgmt. Medical Management Family Engagement

Medicaid MCO

Risk adjusted PMPM for defined population

CLINICAL INTEGRATION

Other Providers

Health Network by Cincinnati Children’s

ACTIVITIES THAT PROMOTE THE TRIPLE AIM

Innovative Case Management

Practice Network Development and Transformation Data for Quality and Financial Management

Value Based Payments Drive Family-Centered Care

• Most Costly Population with

most room for improvement in Value (Quality/Cost)

• Demands increased

resources

• Value-Based Payments

allow innovative financing

• Families have options
• Coordinated Care is Key

– Seamless transitions – Integration with the Health System

• Systemic Improvements benefit all patients/populations

Distribution of Pediatric Medical Expense % of population 0.5% 25% 74.5% Healthy, Preventive Chronic Complex % of spend 25% 70% 5%

Mahmoud

• 6 years old
• Autism Spectrum

Disorder

• Family from Iran, difficulty

understanding/accepting diagnosis

• School supports not

helpful yet no recommendation for specialized school setting

Mahmoud

• Team Mahmoud

– Pediatrician – Parents – Social Worker – Care Manager – BH facilitator

• Identified appropriate

school setting

• Helped family obtain Ohio

scholarship for ASD

• HNCC paid additional

tuition ($4,000)

• Mahmoud is thriving in his

new school, behavior and speech are improving

Estela

• Recently moved in with

aunt, physical abuse at home

• Aunt speaks little

English

• 17 years old, pregnant,

now at 30 weeks

• Had a previous child at

26 weeks who died

• Had preeclampsia with

first pregnancy

• Finished up to 7th grade

Estela

• Team Estela

– Estela – Adolescent Medicine – Nurse Care Manager – BH facilitator – Social Worker

• OB care
• Home Visiting

– Early Head Start – Positive parenting, will continue for 3 more years – Weekly BP checks – Depression, responded to Home based CBT (Moving Beyond Depression)

• Started working on GED
• Had a healthy girl at 37 weeks

Avondale

Cincinnati Asthma Admissions and Neighborhood Asthma Hotspots

Legal Aid Housing Cases Mapped Against Neighborhood Asthma Hotspots

Avondale

Beck (2014)

Avondale

Beck & D. Jones (2014)

“Heat map”

• f building

code violations

Avondale

CHOICE Buildings to be refurbished by Community Builders

Beck (2014)

Avondale

Beck (2014)

Breathing Room: % of students with poorly controlled asthma who completed medical home visit (March 6--June 5, 2013)

PDSA #1 verification of medical home with parent/AAP PDSA#2 develop expedited appointment process PDSA#3 schedule appts utilizing expedited process PDSA #4 Modify expedited process PDSA#5 visit medical home site PDSA #6 persistant phone contact w/family & provider

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 01/30/13 (n=36) 02/06/13 (n=39) 02/13/13 (n=39) 02/20/13 (n=42) 02/27/13 (n=45) 03/06/13 (n=45) 03/13/13 (n=45) 03/20/13 (n=45) 03/27/13 (n=46) 04/03/13 (n=46) 04/10/13 (n=46) 04/17/13 (n=47) 04/24/13 (n=48) 05/01/13 (n=48) 05/08/13 (n=48) 05/15/13 (n=48) 05/22/13 (n=48) 05/29/13 (n=49) 06/05/13 (n=49)

weekly count of students with ACT score <20 % of students with ACT <20 with completed medical home visits

cumulative percentages median Goal (60)

Engaging Cincinnati Public schools in network of care

Baseline (7/07-6/09): 7.2/10,000 Goal ((6/30/2014): 5.5/10,000 As of Feb2014: 5.1/10,000 *Denominator data is from ODJFS, with a lag of 30-45days

New Protective Interventions

Building an Enhanced Theory of Change that Balances Enrichment and Protection

Significant Adversity Healthy Developmental Trajectory Supportive Relationships, Stimulating Experiences, and Health-Promoting Environments

Conclusions

• Advances in developmental science are:
• Forcing us to reconsider the early childhood
• rigins of lifelong health & disease
• Challenging us to “get it right the first time”
• Beckoning for two generation primary care to

“protect the brain” and “build new skills”

CONCLUSION:

It is easier to build strong children than to repair broken men.

Frederick Douglass