Supporting Vulnerable Families Kerryn McGlone & Monique - - PowerPoint PPT Presentation

Complex Pregnancy Care: The Regional Experience in Supporting Vulnerable Families

Kerryn McGlone & Monique Rosenbauer Bendigo Health

What is CPC?

• A model of care within the Maternity Support

Program at BH providing an individualised care plan for vulnerable women and their families.

• Through a multi disciplinary team we provide a

pathway to connect vulnerable women and their families to prevention and early intervention services.

Why do we have CPC ?

• Originated within the Domiciliary service as a response

to the changing psychosocial needs of our women and their families

• These families were found to require intensive supports

to ensure the newborn and older siblings were not at risk

• The supports required and recognised at the home visit

came too late in their pregnancy/birthing episode, as well as waiting times for some supports often were 3-6 weeks

Consequences of no pre birth planning

• Family’s experience
• Perinatal and post birth outcomes
• Operational issues
• Impact on Community Services

How did CPC get started?

• Monthly discharge planning meetings
• Multidisciplinary team
• Consistent individualised plan was developed
• Privacy was paramount
• Preventative approach rather than crisis driven

Current Function of CPC

• Information sharing, identification of risk and discharge planning
• Multidisciplinary team
• All midwives and obstetric staff play a role in identifying complex

pregnancies and referring to the CPC program.

• Especially the ‘Booking in’ midwives
• Combination of referred issues
• Referrals can be and are made at any point along the antenatal

journey.

• Review when complex issues not identified prior to birth

CPC Referrals

• A4 page sheet and is placed in a CPC folder kept on the Maternity

Ward.

• A ‘summary sheet’ of entries
• Noted on the alert sheet in the medical file.
• A monthly meeting occurs in the MSP office
• Sharing if known knowledge been CP and Maternity clients
• A4 sheet CPC plan is completed by the MSC approx 8 weeks prior

to an EDD. The plan is shared with the MCHN coordinator.

• RED copy is placed in the client’s medical history behind the alert
• sheet. Copy to SCBU and MCHN.

Case Conferencing

• CP will coordinate when an unborn report has been made
• MSC will coordinate when CP are not involved.
• All other professional parties involved are invited to attend
• MSP will provide a meeting room within the hospital grounds
• The client is very welcome to include any family members or support

persons they may choose.

• SCBU nurse will also attend to report on the baby’s health and care

needs.

Anecdotal Outcomes

• For Maternity Services
• Clear planning
• Consistency
• Communication
• For external providers

Key points of CPC

• Dynamic and always evolving
• Transparent
• Preventative approach
• Identifying risk and linking supports
• Sharing information between services
• Empowering women and families
• Maintain expected ‘normal’ LOS and MHC visits

Case Study

Ms E, aged 18 years and pregnant with her second child.

Own Background

• Dysfunctional family background
• Removed from her parents care as a

young adolescent due to neglect and physical abuse

• No contact or access with her parents for

some years.

First Pregnancy

• Aged 16 and under the care of CP. In CPC.
• Intensive support from the baby’s paternal family.
• Baby was placed on a Supervision Order
• Relationship breakdown with the baby’s father.
• Mother-Baby Unit admission
• The baby was placed in the care of the paternal family.
• Involuntary admissions to a psychiatric facility
• No access with baby and met a new partner.

Second Pregnancy

• FTA booking in appointment.
• MSC made contacted her
• Accepted a referral to MSP and CPC program
• FTA an appt made with MSC
• Memory difficulties
• Feared CP intervention given history with her first child.
• MSC liaised between CP and client

Second Pregnancy

• Pre-birth case conference chaired by CP
• Young parents engaged with services and consented to

CPC plans

• Plan for baby to remain in parents’ care with a number of

conditions

Outcome

• CP attended the Maternity Ward the day after
• birth. Completed legal processes.
• Discharged home with a beautifully healthy baby
• CP legal intervention for monitoring and a

number of community support services.

• Clear support plan prior to the birth. No distress
• r panic post birth.

Where to from here for CPC?

• Funding
• Increase the EFT commitment
• Research to prove this is an effective

intervention in pregnancy care

• Expansion of CPC further into the region
• Addiction clinic at Bendigo Health

Thank you..

Questions??