the maternal-child health intervention group (mch

Transcription

THE DURHAM HEALTH
INNOVATIONS PROJECT
________________________
THE MATERNAL-CHILD
HEALTH INTERVENTION GROUP
(MCH GROUP)
COMMUNITY CO-LEAD:Tamera Coyne-Beasley, MD, MPH
UNC-CH Department of Pediatrics
and Internal Medicine; Community
Health Coalition
COMMUNITY CO-LEAD: Sue McLaurin, MEd, PT
Community Health Coalition
DUHS CO-LEAD: Monique Chireau, MD, MPH
Duke University Department of Obstetrics
and Gynecology
DUHS CO-LEAD: Maria Small, MD, MPH
Duke University Department of Obstetrics
and Gynecology
TEAM MEMBERS
Sharon Baker, JD
Community Health
Coalition, Inc.
Lottie Barnes, MPH,
CHES
Safety & Health Specialist,
Radiation Safety Division,
Occupational
Environmental & Safety
Office, Duke University;
Volunteer, Community
Health Coalition
Tammy Bishop, RNC,
MSN
Program Manager, Duke
University Department of
Obstetrics and Gynecology
Bobbie Brown, RN, MSN
Assistant Professor, North
Carolina Central University
School of Nursing
Haywood Brown, MD
Chairman, Duke University
Department of Obstetrics
and Gynecology
Kim Dau, RN, CNM, MSN
Duke University
and Gynecology
Janeen Gammage, BA,
MSLS Ivy Community
Center President, Alpha
Kappa Alpha Sorority Inc.,
Duke University School of
Law Library
Sue Guptil, RN, MSN
Nursing Director, Durham
County Health Department
William Hackney,
Administrative Assistant,
Duke University
and Gynecology
Elaine Hart-Brothers, MD,
MPH Chair of the Board,
Community Health
Coalition
Jimmie Hawkins, MDiv
Pastor, Covenant
Presbyterian Church
Diane Holditch-Davis, RN,
PhD, FAAN Associate
Dean, Duke University
School of Nursing
Rachel Peragallo, MD
Duke University
and Gynecology
Elizabeth Jensen
Project Coordinator,
Durham B.E.S.T. Babies
Alliance, University of North
Carolina Chapel Hill
Department of Maternal
and Child Health
Rhonda Reaves
Financial Analyst II,
and Gynecology-Office of
Research Support, Duke
University Medical Center
William Lawrence, MD
Wake County Medical
Director, Duke University
Primary Care
Evelyn Morrisey, BS,
LD/RD, D. MIN Licensed
Dietician (Ret) and
Associate Minister; Ivy
Community Center, Alpha
Kappa Alpha Sorority Inc.
Sarah Nahm, MPH, RD,
LDN Nutritionist, Durham
County Health Department
Renee Parks-Bryant,
Health Education
Specialist, Durham County
Health Department
Jessica Simo, MHA
Network Coordinator,
Durham Community Health
Network, Duke Division of
Community Health
Rosa Small, BS, MSLS
Media Coordinator, Ivy
Community Center, Alpha
Kappa Alpha Sorority, Inc.
Geeta Swamy, MD, MSS
Duke University
and Gynecology
Kevin Thomas, MD
Duke University
Department of Cardiology
Ingrid Wicker-McCree,
EdD Athletic Director, North
Carolina Central University
Elizabeth Woods, MA,
MPH, Community Health
Coalition, Inc.
TABLE OF CONTENTS
_____________________________________________________________________________________
HEALTH NEEDS & METRICS .......................................................................1
BUILDING THE TEAM & COMMUNITY ENGAGEMENT...............................2
MODELS OF CARE FOR 10 EMPHASIS AREAS.............................................5
KEY ELEMENTS OF A CONNECTED CARE MODEL FOR SUCCESS OF
PROPOSED TEAM MODEL OF CARE .........................................................15
REFERENCES ..............................................................................................19
APPENDICES ...............................................................................................22
APPENDIX A - INFANT MORTALITY: DURHAM, NC, 2003-05
APPENDIX B - LEADING CAUSES OF INFANT MORTALITY
APPENDIX C -TRADITIONAL CARE VS. INTERNATAL CARE
APPENDIX D - PREECLAMPSIA/ECLAMPSIA DURHAM CO MAP, 2007
APPENDIX E - MATERNAL OBESITY, 2007
APPENDIX F - LOW BIRTH WEIGHT, 2007
APPENDIX G - MATERNAL HYPERTENSION, 2007
APPENDIX H -MATERNAL DIABETES, 2007
APPENDIX I - OUTCOME MEASURES
APPENDIX J – TEAM MEMBER DESCRIPTIONS
APPENDIX K – PROPOSED PRECONCEPTION CARE CONTENT
APPENDIX L - TRADITIONAL PRENATAL CARE VS. CENTERING
PREGNANCY® GROUP PRENATAL CARE
APPENDIX M -INTERNATAL CARE MODEL
APPENDIX N- INTERNATAL CARE CURRICULUM
MATERNAL-CHILD HEALTH
HEALTH NEEDS & METRICS
Define health needs
In Durham County, North Carolina, adverse maternal-child health outcomes such as low birthweight and
infant mortality occur at higher than national average rates and disparately across racial-ethnic groups
(Appendix A). According to the Durham, North Carolina 2007 Health Needs Assessment, the overall
infant mortality rate is 7.2/1000 births and the rate among minorities 12.6/1000 (Smith, 2007). Low
birthweight, a leading cause of infant mortality, occurred in 99.7/1000 live births in the general population
and 128/1000 live births in minorities. These numbers are much higher than the Healthy People 2010
national infant mortality and low birthweight targets of 4.5/1000 live births and 50/1000 live births,
respectively. The Durham North Carolina 2007 Health Needs Assessment identifies reduction in low
birthweight and infant mortality a priority for health improvement (Smith, 2007). The infant mortality rate,
and especially the racial disparity in the rate, is a great concern to public health officials in Durham
County (Appendix A). North Carolina continues to be ranked as one of the states with the highest infant
mortality rates in the US. In 2008, The March of Dimes gave North Carolina a score of ‘F’ for preterm
birth, a leading cause of infant mortality (March of Dimes, 2009).
The causes of low birthweight and infant mortality are complex and not fully understood but are related to
maternal outcomes. Maternal obesity, diabetes and hypertension carry substantial short- and long-term
risks for both mother and child. Obesity is associated with hypertension, diabetes in pregnancy and low
birthweight (Caughey 2006; Hall, 2005; Magriples, 2009; Pathi, 2006). Hypertension in pregnancy is
directly associated with low birthweight (Caughey 2006, NC Center for Health Statistics [PRAMS], 2006).
Women with hypertension or diabetes in pregnancy are also at increased risk for future cardiovascular
disease (Bellamy, 2007; Kim, 2002). Infants born to obese or diabetic mothers are themselves more
likely to develop early obesity, diabetes and vascular disease (Barker, 1990). Exercise can reduce the
risk of diabetes and hypertension in pregnancy (Dempsey, 2004, 2005). Interventions to improve
maternal health before the next pregnancy have the potential to improve maternal-child health.
The prenatal period is an ideal time for behavior change due to women’s concern for their unborn child
(Meade, 2005). The postpartum and interconception periods may be equally ideal for improving future
pregnancy and long-term health. For example, folic acid use, weight loss, smoking and alcohol
cessation, and blood pressure and diabetes management can reduce congenital malformations (the
leading cause of infant mortality in the US) (Appendix B). Prematurity and low birthweight are the leading
cause of infant mortality for African Americans (Matthews, 2008), but prenatal care alone has not been
shown to improve birth outcomes, especially if preconception or early pregnancy counseling and
interventions are inadequate (Lu, 2006). For interventions to be effective, they must begin months
before pregnancy because the critical period of organ formation and placental development occurs
before a woman is even aware of pregnancy. One preconception visit is not sufficient to address chronic
illness management or prevention (Lu, 2006). Internatal care occurs following the delivery of one child
and continues through the delivery of the next (Lu, 2003, 2006) (Appendix C).
Infant mortality and adverse maternal health outcomes illustrate areas of health disparities. Nationally,
and in Durham, NC both infant mortality rates and rates of adverse maternal outcomes, such as severe
maternal obstetric morbidities and maternal mortalities, are higher in minorities (Smith, 2007 [Partnership
for a Healthy Durham]; Brown, 2007). For African American women, adequate prenatal care, and higher
socioeconomic status does not decrease the risk of adverse outcomes when compared to Caucasian
women. Many investigators posit the maternal health disparities experienced by African American
women may result in part from complex societal, and community based stressors such as racism and
neighborhood level inequalities (Lu, 2003; Collins, 1997; Collins, 1997; Hearst, 2008; Kramer, 2008). In
Durham, sharp differences exist in the neighborhood level prevalence of adverse maternal outcomes.
Investigation of the contribution of environment to maternal-child health is ongoing (Appendix D-H).
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What are the key health metrics that can be used to measure the current state of health and to
judge whether we have an improvement in health in Durham County?
A primary goal will be to improve maternal and neonatal/child health outcomes such as low
birthweight/infant mortality. Short-term measures of success will include improvement in maternal health
status, as measured by improvement in healthy behaviors such as folic acid consumption/prenatal
vitamin usage, increase in interconception (interpregnancy) intervals, smoking cessation, increase in
physical activity levels, and improved stress management. Biological markers of improvement will
include weight reduction, blood pressure control at target range, blood glucose control, LDL/HDL at
target range.
The short-term follow-up measures such as weight reduction, blood pressure, blood glucose control will
be measured and recorded monthly. Target cardiovascular markers will be assessed at baseline and at
the end of the group sessions of one year. We anticipate follow-up for subsequent pregnancy results will
occur 2-3 years following the index pregnancy. Long-term measures will include improved outcomes in
subsequent pregnancies. A long-term community level goal is to reduce infant mortality (Appendix I).
Other measures of measures of success will include decreased use of emergency department services
for primary care issues, improvement in health literacy, knowledge of the health system, and comfort and
satisfaction with the health model on behalf of participants and primary care providers. Many markers of
cardiovascular disease overlap with the conditions associated with placental vascular disease and
provide the link between maternal health and adverse perinatal outcome (Magnussen, 2009).
BUILDING THE TEAM & COMMUNITY ENGAGEMENT
How did your team come together?
To address the issue of women’s health between pregnancies, the Maternal-Child Health Intervention
Group sought to involve equal collaboration between the Health System and the community from the
start. The Internatal Care team’s first members included a group of individuals from both Duke and
community settings, including the Durham County Health Department, the Community Health Coalition,
Alpha Kappa Alpha (AKA) sorority, and the faith community (Appendix J). Early on, these groups began
to work together as equal partners to blend resources and share responsibilities. At the first meeting, the
group identified key individuals who agreed to sign on as Co-Leads for the project. The Health System
Co-Leads included professionals with extensive expertise in the subject matter and who were engaged in
clinical practice. The community Co-Lead had expertise in recruiting community representation and
activating and mobilizing the community in order to engage residents in relevant activities.
Team leaders recognized that receiving “buy in” from community stakeholders and consumers was
critical to achieve the project’s goals. Likewise, the team saw that gaining trust from community
members by demonstrating respect for their expertise, customs, and values was equally important. After
the initial team members began to meet weekly, it was quickly recognized that no one person could
speak for the community; thus, the Internatal group began to think of how to expand the team to include
others. Core team members were recruited based on their experiences in the community and with the
maternal and child (MCH) population. Many members were recruited from groups that focus on MCH
issues, such as the Infant Mortality Reduction Committee and the Internatal team breakout session at the
Duke/Durham Health Summit. The group also included other community stakeholders. Thus, the team
now includes members of the Community Health Coalition who have been working on breastfeeding
efforts with African American women in Durham; a nutritionist who works specifically with pregnant
women in the community; a pastor from a local church was recruited to facilitate communication with
other members of the faith-based community; faculty and staff from North Carolina Central University’s
nursing and physical education departments; a person with contacts in Durham public housing
communities; and members of African American sororities. Marketing and community engagement
efforts have also resulted in partnerships between the Internatal team and organizations throughout the
community with a similar interest or focus, such as Welcome Baby and Durham Connects.
2
What is the full complement of existing programs, resources, and partnerships in Durham County
relevant to your team’s primary focus?
Durham County has a wide variety of resources available to women before, during, and after pregnancy.
Unfortunately, many of these resources are not easy to access, are underfunded, or do not have the
capacity to serve the entire county. These resources provide direct patient health care or preventive
services. Some of the resources that provide service to the MCH populations in Durham include:
 Duke and Durham County Health Department’s OB clinics (including the Centering Pregnancy
groups) and other health and community services
 Family planning clinics
 Lay health advisors program
 Welcome Baby
 Durham Connects
 B.E.S.T. for Babies breastfeeding project and other Community Health Coalition programs
 Infant Mortality Reduction Committee (Partnership for a Healthy Durham)
 Teer House
 WIC
 Faith communities and ministerial associations – offer support and education
 El Centro Hispano
 Baby Love Program
 Durham’s Partnership for Children
 Children’s Developmental Services Agency
 Child Care Services Association
How did the existing programs, resources, and partnerships shape your team’s thinking?
The Internatal Care team demonstrated the tenets of the community-based participatory research
(CBPR) model in that it engaged the community; integrated local knowledge and experience; and
created community investment in the research process (Israel, 1998). CBPR principles guided us in our
planning for activities and engaging the community. Team members from the Duke Health System
represented strengths in clinical practice and research, while Durham community members voiced the
need for patient-centered care that was community-based and neighborhood friendly. This partnership
was driven by a strong reliance on collaboration and trust. From the beginning, the team recognized all of
the resources of the partnership. Thus, all participants at the table had a voice in the decision-making
process. It also became evident that individuals possessed strong feelings about their roles in the
planning process and were able to represent various nuances of the health system and the community
that needed to be considered during the planning process. This proved to be strength of the team.
From the beginning, the term “Internatal” Care Model was defined and team members reflected on their
own perceptions of community resources related to the model. Lack of resources and diminished
community capacity were also addressed. In this review of the community, the team identified gaps in
health services and made suggestions for healthcare priorities and community capacity building. For
example, the team identified the major healthcare providers in the Durham community as well as nonhealth community resources such as child care settings, schools, recreation programs, public housing
communities, beauty parlors, grocery stores, shopping centers, churches and faith-based programs, and
other places frequented by young women. All resources can impact a woman’s health and her ability to
make good choices to prepare for a healthy pregnancy. Thus, a comprehensive process was conceived
during the first stages of the planning phase and remained the focus for its entire duration.
How did you ensure broad community input and involvement?
This team is comprised of representatives from the Duke Health System and various community
organizations. When the original members began the planning process, they readily identified that other
community resources needed to be involved and representatives from those groups were invited to
become a part of the team. Thus, the group grew as the assessment of needs developed. The team
built the planning process around current research on internatal care. The key was to apply that
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research to the needs of the Durham community and to identify important variables that needed to be
addressed in the community. As the needs of childbearing women in the community were identified, the
group began to identify resources and persons with the expertise to respond to those needs. The
Durham community is comprised of a myriad of individuals from diverse backgrounds who could be
called upon to provide their expertise during the planning process. Whenever it became apparent that
some component was lacking, team members began to provide names of others to consult with and/or to
include in our efforts.
The most striking feature of the team was the spirit of cooperation and trust that were present. This did
not mean that people agreed with each other all the time, rather that the team respected diverse
opinions. In the end, a great amount of good will and synergy was generated from the group. In other
words, this was an example of a real partnership between a health system and a community.
An example of the community members’ integration in the team was the Duke IRB certification of several
members to become focus group facilitators and interviewers. This was quite extraordinary because it
showed how the Duke Health System validated the expertise of the community members as advocates
and enablers of their own community. Others used their influence with community groups to recruit
participants for the focus groups, and others worked along with the Duke Health System staff to interview
key informants in the Durham community to ascertain their view of the status of healthcare services in
the community with an emphasis on women’s health. We will use information gained from the focus
groups and key informant interviews to determine key elements that have to be considered in planning.
Four focus groups of Caucasian, African American, and Latina women were held, as was a group of local
clergy. The women groups provided their perceptions and feelings regarding women’s health issues in
the Durham with particular emphasis on healthy pregnancy outcomes, healthy behaviors, and adequate
health resources. The Clergy’s group provided information on the relationship between faith-based
organizations and women’s health and their beliefs about the significance of spiritual, mental, and
physical connections to women’s health. They also provided their perceptions about health resources in
the community. Community stakeholders provided broad feedback on the health concerns of the
community, gaps in health services, barriers and challenges to healthcare delivery, and outreach to
vulnerable populations.
What input/assistance did you get from the Oversight Committee and the Technical Assistance
Cores?
The oversight committee and technical assistance cores provided our team with resources and direction.
Although, the process of conceptualizing a new model of care for the entire system at times seemed
cumbersome and frustrating, the oversight committee was receptive to the perceptions of the team
members. These discussions and support for honest dialogue were essential to the formation of broad
coalitions of groups and individuals. These discussions helped establish the trust needed to engage
both the academic community and the larger Durham community around MCH health issues.
The technical support structure was well conceived, helpful, and innovative. The assistance with IRB
preparation and expediency was invaluable. The combined statistical support, geospatial mapping, and
economic analysis cores provided the team with the type of expertise necessary to address priority
health issues. The work of deciphering the voluminous DSR database is ongoing. This work, as well as
that of the environmental core, provided a framework for addressing the scope of the targeted public
health issues. This core work may also form the basis for community activity directed at these health
issues. As a result, many communities may now have the evidence and support needed to address
health issues based on the unique characteristics of their particular locales and resources. This
approach is evolving in Durham, largely because of the involvement of individuals from the technical
assistance core.
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What did the community engagement process teach your team about the problem and each
other?
Once our diverse team of medical professionals, community health workers, and community members,
was assembled, we met on a regular basis. At the group meetings, the project manager and Co-Leads
led the discussion and all members were equally able to participate in the decisions and planning. This
minimized power differentials common in research projects between community members and
academicians. Some members had specific roles, such as data acquisition, literature review or focus
group planning. These individuals came to the meeting and presented their work to the rest of the group.
Eventually, the group split into small groups to work on specific areas of the project such as community
participation, health model development, or data analysis.
Responses from the community taught the team a lot about women’s non-medical concerns. When
asked if she saw a healthcare provider when she is not pregnant, one woman responded, “I don’t go
because I don’t have medical insurance. I have to feel bad (to go to the doctor); otherwise I don’t go.”
This response epitomizes why pregnant women continue to have low birth weight babies. The team also
learned that women feel physicians don’t adequately address mental health. Focus group responses
validated the need for more maternal support and stress reduction services. Women verbalized an
important reason for internatal care: when women have limited resources, medical and physical needs
are not their top priority. Instead, they want to have non medical services to meet their basic needs; such
as child care support, balancing family and work responsibilities, and feeling less stress. The Team
quickly recognized the priorities of women and the need to develop a responsive model, to address their
concerns.
The discussions were rich as representatives from different backgrounds gained new perspectives on
providing internatal health care for women with poor pregnancy outcomes. It became clear that although
keeping medical appointments was important, the healthcare system had to be sensitive to the barriers
women faced. Community health workers discussed how to run an effective community intervention;
health care providers added insight about which interventions were most effective, and community
members spoke about which interventions would most likely be utilized. Making decisions about the
model of care took longer than it would have if fewer people had been involved, but the resulting model
was well thought out and inclusive of a variety of perspectives. Working in a group taught individuals
how to focus resources on shared goals and ideas. Members were willing to give up personal agendas,
when necessary, for the good of the common goal: improving maternal and infant health. As a result of
this process, team members kept themselves accountable to patient needs as determined by qualitative
research in the community. This group exemplified community-based participatory research ideals and
will continue this process as it seeks funds for implementation.
MODELS OF CARE FOR 10 EMPHASIS AREAS
What is the model of care that your team is proposing?
What evidence currently exists that this model is viable – particularly in Durham County?
Prenatal care models target medical problems and conditions affecting a woman’s health or the health of
her unborn child during pregnancy. Despite the concentrated policy focus on prenatal care, rates of low
birthweight and preterm birth have actually increased in the US (Lu, 2006). Increasing evidence supports
the importance of addressing high-risk maternal medical conditions, exposures, and psychosocial
conditions before pregnancy (Lu, 2006). The standard, single preconception visit, designed to address
these conditions, may be insufficient for women requiring more intensive, ongoing interventions to
address these conditions. This situation may prove particularly important for women at highest risk, not
only because of medical co-morbidities and adverse outcomes, but also due to social conditions such as
limited access to health care between pregnancies or limited understanding of their co-morbidities and
future pregnancy risks. A ‘life course’ model takes into account cumulative events and stresses, which
may impact a woman’s health (Lu, 2006). This model supports the concept of ‘early programming and
cumulative pathway.’ Early life experiences may accumulate over an individual’s lifespan and
eventually impact birth outcomes (Lu, 2003). For Example, fetal exposure to under nutrition may result
5
in eventual adult cardiovascular disease (Barker, 1990). Chronic stress may contribute to the age
related; four fold increase in low birthweight infants for African American women as compared to White
women in the US (Geronimus, 1996). Acute and chronic stresses from life events (e.g. intimate partner
violence), homelessness, neighborhood safety, and food/job insecurity may adversely impact birth
outcomes (Lu, 2003). The model expands beyond individual level health care, and takes into account the
biological, psychological, behavioral, and social determinants of health (Lu, 2003) (Appendix C).
This model is novel, and few examples of outcome related successes exist in the literature. Most studies
of interconception care focus on success in implementation and acceptance of interconception care
models (Posner, 2008). Sites in Denver, Atlanta, and Philadelphia used interconception care—from the
birth of one child (point of entry) to the delivery of the next (endpoint) to demonstrate reductions in
adverse outcomes such as preterm birth for high-risk women (Lu, 2006; Dunlop, 2008). An internatal
care program in Denver, Colorado focused on case management approaches for high-risk women with
prior low birth weight infants, congenital anomalies or stillbirths. Women were interviewed at baseline for
risk assessment and worked with developed individualized health goals. Participants received support
with health system navigation, job training, substance abuse, and problem — solving. The program was
designed to improve social support and reduce stress scores. Success of the program was measured by
behavioral changes, follow-up with post partum care, and measures of life course achievements (e.g. job
training, GED classes). Although the number of participants was small (n=277), in the 35 women with
subsequent pregnancies, fewer women had late or no entry to prenatal care as compared to the general
obstetrical population. Women enrolled in the intervention demonstrated 20% reduction in unmanaged
personal problems (Loomis, 2000). A preconception care program in Pennsylvania demonstrated
improvement in women’s self reported health behaviors measured by increased activity levels, food label
interpretation, and folic acid usage (Hillemeier, 2008). As this intervention approach is new, little
evidence exists in the literature on the direct impact of preconception care programs to reduce infant
mortality or preterm birth (Posner, 2008). One area of the country, Dane County Wisconsin experienced
a precipitous dramatic decline in African American infant mortality rates. Initial rates in the city, similar to
the rest of the state, were three times those of whites, however over the last decade they reached par
with Caucasian infant mortality rates. Although the etiologies of this decline are unclear, they are driven
by declines in preterm birth rates, and may parallel overall community—based efforts to improve
maternal health. Some of these efforts include a ‘one stop’ maternal care center that addresses medical,
social, and financial/job needs. They also describe an extensive group of community-based nurses and
social workers that perform both prenatal and postnatal visits to mothers at risk for preterm birth (MMWR,
2009; Eckholm, 2009).
There is no consensus on what the content of internatal care should consist of, nor is there consensus
on how frequently women should be seen by health care providers during this time period (Lu, 2006).
There is no clear definition of who should provide this care. There is, however, consensus among many
professional groups that certain key components should be present in preconception care for all women.
The National Heart, Lung, and Blood Institute (NHLBI), for example, recommend that women with
hypertension, diabetes, and obesity have risk assessment and clinical and psychosocial interventions to
improve pregnancy outcome (Lu, 2006). The American College of Obstetrics and Gynecology (ACOG)
and Joint Commission on the Accreditation of Healthcare Organizations (JCHAO) recommend screening
for violence in this time period, as partner violence is associated with low birthweight (Valladares, 2002).
Other components of this care endorsed by organizations such as Health and Human Services (HHS)
and ACOG include immunizations and elimination of exposures such as tobacco, alcohol, and illicit drugs
(Lu, 2006).
In 2006, the Centers for Disease Control (CDC) identified preconception care as a national priority and
established guidelines for preconception care, that should include activities to:.
1. Improve knowledge, attitudes and behaviors of men and women about preconception health
2. Ensure that all women in the US receive preconception services that will enable them to enter
pregnancy in optimal health
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3. Reduce risks as indicated by adverse pregnancy outcomes through interventions during the
interconception period to prevent or minimize health problems for a mother and her future
children
4. Reduce disparities in adverse pregnancy outcomes
(Johnson [CDC}, 2006)
In 2008, the state of North Carolina identified preconception care as key component to the health care of
children (NC Division of Public Health, 2008). The health issues for women of child bearing age included
problems such as: 24% of women using tobacco, 47% not meeting minimum physical activity
recommendations, 28% being obese, 10% having hypertension, 3% having diabetes, and 71% not taking
folic acid at least 5 days a week. The NC Division of Public Health identified preconception health as,
“vital to North Carolina’s future…better preconception health improves the overall health of women and
babies, decreases health disparities in our state, improves our health care system and decreases cost to
families and society.” (NC Division of Public Health, 2008) (Appendix K).
The Maternal-Child Health Intervention Group designed an internatal care program that incorporates
established recommendations for preconception care, based on NC State and CDC guidelines. This
model will focus on the most high --risk, reproductive age women—those who have had a poor
pregnancy outcome and/or because of maternal health conditions such as obesity, hypertension, or
diabetes are at risk for future adverse health outcomes. Our model will include baseline risk assessment
performed near the time of the recent delivery, but before 8 weeks postpartum. Women will be invited to
enroll in the group based, health promotion model
which will provide social support and health
education, nutrition, fitness instruction, stress management, life course support, and as assistance with
reproductive health and family planning goals.
Women will be linked to primary care providers for ongoing, individualized preconception support based
upon their individual health needs. Needs may only include contraception management or may involve
close management of blood glucose and blood pressure. This program will serve as a bridge and
supplement to individualized, primary care provider--assisted internatal care. The group model will
facilitate social support and efficiency for group level health promotion messages and interventions.
The group approach to prenatal care, “centering prenatal care”, is one Durham has engaged in and is
an effective model shown to provide social support for women in a group care context. In this model,
participants begin sessions with stress management exercises, then check their own blood pressures
and urinalyses, and spend 2 hours with a CNM or MD. Typical sessions include 12-15 women, so actual
contact time with a health care provider is increased compared to traditional care. In a randomized
clinical trial of centering vs. traditional care conducted in 2 urban, public obstetric clinics in New Haven,
Ct and Atlanta, Ga, women who participated in centering had decreased preterm birth rates and higher
birth weights (Ickovics, 2007). The group model, and centering pregnancy programs, adapt to the
cultural and linguistic needs of participants. Multiple descriptive works from diverse populations show an
improvement in health literacy, empowerment, and decreased recurrent teen pregnancy rates (Rising,
1998; Grady, 2004; Massey, 2006) (Appendix L).
Clinical nurse midwives from Duke University have used the centering pregnancy model to provide
group prenatal care at Lincoln Community Health Center since 2004 (Quinn, 2007). In work matching
centering pregnancy participants from Durham, NC to women who did not participate in centering,
African American women in the centering groups were more likely to breastfeed and more likely to
attend prenatal visits than those attending traditional care (Quinn, 2007). Breastfeeding rates for African
American women attending public health clinics in Durham, NC, are much lower than the population at
large (CHAMP, 2008).
“Expanded centering’ addresses key informational content specific to the need of the population
involved. In the largest randomized clinical trial of centering from urban, largely young population,
participants received expanded education on HIV/AIDS education as well as, education on self -
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protective behaviors against violence (Kershaw, 2009). Participants in the expanded education
centering groups had lower rates of sexually transmitted infections and reported improvement in sexual
negotiation skills and condom usage. ‘Expanded centering’ addresses key informational content
specific to needs of the population involved.
The group care model is innovative and effectively used to deliver prenatal care throughout the US but is
not widely applied for internatal care. The MCH team developed a group internatal model, appropriate to
the needs expressed by stakeholders, patients, and community members. This program will link highrisk postpartum women, providers, and programs serving pregnant/postpartum women and children. The
model will have collaborative community and institutional input during its implementation.
What services will be provided?
Post partum Centering Group services
Focus group participants sited the following issues informing the proposed model of service delivery:
 Need for neighborhood services
 Clinics should include health promotion services
 Have healthcare workers that “look like me”.
 Better coordination of healthcare services
 Increase need for health education in the community
 Implement access to care campaign. Medical Care Options, for the greater Durham community.
(Partnership)
Within the internatal groups initial medical services will include blood pressure and weight screening
Health education sessions in an ‘expanded’ centering format will focus on the needs of the women in the
groups and include messages delivered by primary care providers and specialists focused on diabetes
education, hypertension management, breastfeeding support, HIV/AIDS education, importance of
consumption of folic acid, contraception options. Women will be exposed to health educators, resources,
and health care providers who are available to provide follow up information to group participants.
Nutrition and fitness will play a key role in the monthly group sessions. All sessions open and close with
stress management exercises. Women will also have contact with and support of spiritual leaders who
express a strong interest in women’s.
The groups will take place in community based settings such as churches, community centers, and
locations identified by women as “accessible spaces of comfort and trust.” Initial groups will take place
in neighborhoods/communities with high rates of infant mortality and adverse perinatal outcomes.
Groups will introduce women to other community based, volunteer support for mentoring and parental
support such as Durham County Health Department’s “Granny/Mother Mentors’ and “Strong
Couples/Strong Children,” parenting support group. Through the planning process, out team identified
other men and women’s groups interesting in supporting this effort as part of their community service.
Primary Care Services
This model emphasizes an increase in community access to primary care services. Although the
Durham Community is nationally and internally recognized for medical advances, its local community
maintains pockets of high-risk individuals where care is not an option, simply because of lack of
resources to constantly seek care as the current medically created model is established. As a result, this
medical model has insufficiently met the needs of the highest risk medically residents of the Bull City
community; the community’s response has created an economic deficit for local medical center and its
supporting hospitals.
Internatal care participants will have a two- week postpartum visit with a designated Internatal care group
provider (either CNM, RN, OR MD) in the office, primary community health clinic, or health department.
The participant will initially be connected to those services through an ‘internatal care navigator’.
These initial visits will assess baseline health status; acute health needs, conduct mental health
status/depression screening, and provide breastfeeding support. At the initial visit, the Internatal Care
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provider will also initiate the conversation about current and future health goals and heath (including
reproductive health) planning. A mental health provider will be available to assist mother’s who screen
positive for depression. In settings such as the DCHD, women can easily be directed to ancillary support
services; however, other settings may require coordination through the ‘internatal navigator.’ A home
visit will assess home health concerns such as child proofing of the home, and support needs of the new
mother and neonate. If Durham Connects does not extend to that participant’s community, the ‘internatal
navigator’ or Baby Love worker may visit the home.
Four to six weeks postpartum, women will have an individualized visit to perform a postpartum exam to
readdress health needs and goals, including family planning. This visit is the typical ‘post partum’ care
visit, and represents the last reimbursed visit for most women with Medicaid. Women with pregnancy
related conditions such as gestational diabetes and gestational hypertension should be screened for
chronic hypertension and Type 2 diabetes at that postpartum visit. Most women participating in the
internatal care groups will attend at least one group session before their six-week postpartum visit.
Women without personal co-morbidities will meet with a CNM or RN in their primary care sessions at two
weeks post partum, six weeks postpartum, and one year postpartum. Women with chronic medical
condition such as diabetes or hypertension, requiring medication will meet the individual provider (MD) at
two weeks, six weeks, and every two to three months for one year. Women with chronic conditions will
be referred to appropriate subspecialty care as needed.
What populations does your proposed model seek to serve?
Out target population includes adult women of reproductive age (ages 18-45) of all ethnicities, from
Durham, NC, with recent pregnancies complicated by: obesity, hypertension (including preeclampsia
and eclampsia), diabetes (gestational and pregestational) and/or low birth weight infants.
Who will provide the services?
Certified Nurse Midwives, MD’s, and RN’s will conduct internatal care groups. Co-facilitators may be
students (Duke or NCCU Nursing School), residents, or other support individuals such as social workers
or health educators. In collaboration with NCCU, a RN with clinical experience in prenatal delivery,
postpartum care, and newborn services will conduct groups in conjunction with senior nursing students.
Nursing students with pervious supervised clinical experiences in maternal child health will be trained in
the centering model, and will co-facilitate groups with their faculty mentor. NCCU students are required to
engage in community service as part of their degree requirements. Nursing students may apply their
work with the internatal group toward fulfillment of this service requirement.
Women with high risk for medical conditions such as chronic hypertension requiring medications, or
diabetes, will have group sessions conducted by a MD. Midwives and RNs will lead groups of women
without these types of chronic medical conditions. Eventually, women who complete participation in the
group model may choose to serve as co-facilitators.
An “internatal navigator,” a Health Educator, Social worker, or Nursing Assistant, will facilitate baseline
screening of women eligible for the group care model, and will also facilitate the entire process of
coordination/collaboration with existing services and individuals. This individual will have training in both
maternal and child care coordination/navigation.
This model will increase community access to preventive health messages and promotion of newly
formed community centered clinical services via the partnership of Lay Health Advisors (LHA). This
approach for the need for wider community health education and delivery was identified by the
community activist focus group, “Many things can be done to help people get healthy messages.” LHAs
are individuals who are either indigenous to the community, or have access to and acceptance by the
populations they serve, and viewed as “informal leaders” and experts on a wide range of issues. As
such, they play significant social and cultural roles in their communities (Earp, 1999).
9
Specific activities that the LHAs will carry out in this model include:
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Instructing communities how to successfully enter community centered services
Conducting ongoing follow-up management for high risk women after they enter services
Teaching basic self management, health promotion
Promoting self-managed proactive behaviors
Instructing the highest risk population self-management (BP, weight, etc.)
Where will the services be provided?
During focus groups, new mothers expressed a desire for increased home visits and for providers and
policy makers to ‘go where they are.’ The clergy expressed interest in supporting groups in their
churches and new mothers expressed interest in decentralized, neighborhood—based support services.
Internatal groups will take place in a variety of community based locations, including churches,
community centers, and neighborhood health centers (Appendix M).
Navigating “Mrs. Durham” Through the Internatal Care Model
Mrs. Durham started pregnancy a little overweight (BMI =31) and gained 50 lbs during pregnancy. She
just delivered a low birth weight infant. She has Medicaid and received prenatal care at Lincoln
Community Health Center/DCHD.
Shortly after delivery, Mrs. Durham will be invited to participate in the group care model by a hospital
based Patient Resource Manager (PRM), Social Worker, or community based Maternal Child Care
Coordinator, or Lay Health Advisor. She heard about the program from her Baby Love worker after
seeing the notice on the information bulletin board in the obstetrics clinic. She is worried about her baby,
but would like to participate in the program because she wants to be as healthy as possible.
Mrs. Durham is introduced to her ‘internatal navigator'. Her navigator is a trained Social worker, Nursing
Assistant, or Health Educator from her community who will, not only help understand and ‘navigate’ the
health system, but will connect her with the appropriate Postpartum Group. In Mrs. Durham’s case, her
group will be comprised of women who, similar to her, have personal and obstetric conditions that place
them at high risk for a baby with low birth weight in the future, and for future personal health problems.
Her Group leader will be either a CNM or RN.
If Mrs. Durham had chronic hypertension, diabetes or other medical conditions, her group leader would
be a primary care physician (Internal Medicine, OBGYN, Family Medicine). Her internatal navigator
would assist in connecting her to subspecialty care with a Diabetes or Renal specialist if her medical
condition warranted closer monitoring.
Mrs. Durham is very happy to hear that her Group meeting will occur at the Ivy Community Center near
her home on Fayetteville Road. She has already heard about other post partum women from her
community who will meet in the same location. She is happy to hear childcare will be provided during
group sessions. She also heard they are going to give her diapers at the time of the group session. This
is wonderful news, since diapers are not covered by WIC. Mrs. Durham even knows some ladies from
the community who call themselves ‘mommy mentors’ who are planning to work with the group, and help
her with her baby.
Mrs. Durham will first have a private visit with either her group leader of one of the other Group/internatal
care providers within two weeks of her delivery. At that two week visit, Mrs. Durham and her provider will
address the following issues: her individual health needs, the events related to her delivery and their
potential impact on her health and that of her child, breastfeeding support, changes she may need to
make in terms of medications, or substance use, and stress/depression screening. She will begin an
individual life “health plan”.
Mrs. Durham’s group sessions will occur every month for 9 months, then once every 6 months. The
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group will consist of about 15 other women. Women will discuss formation of health plans and how to
measure and record their own health information (e.g., blood pressure, weight). They will develop health
and fitness goals and learn to understand their own ‘health numbers.’ At the beginning of each group,
participants will measure and record their weights and blood pressures. A fitness leader and nutritionist
will participate in each session and will address fitness activities that are practical for new mothers and
nutrition education. Group members will share a healthy snack. Mrs. Durham will participate in twice
weekly fitness sessions recommended by her Group leader and will meet monthly (at the time of the
group session) with the fitness instructor. Although the group is near her home, if she needs
transportation there, it will be provided for her. Mrs. Durham and the other participants will receive a
notebook containing core curriculum topics (Appendix N). However, they will feel free to address any
concerns they may have.
Mrs. Durham will meet with her midwife or nurse at 2 weeks of delivery, 6weeks of delivery, and one year
after delivery. If Mrs. Durham had a chronic medical condition such as diabetes or hypertension,
requiring medication, she would meet her individual group provider (MD) at two weeks, six weeks, and
every 2-3 months for one year.
Mrs. Durham’s ‘internatal navigator’ initially made contact with her Baby Love worker and Mrs. Durham’s
navigator also made sure she had contact with a home health RN, from Durham Connects within the first
two days post partum. She will make regular phone contact with Mrs. Durham to ensure she is able to
use other home services available to her through the DCHD. Her ‘internatal navigator’ is also available
to assist with resources and needs for her child.
Mrs. Durham has new stressors that make attending groups a challenge. She is a caregiver for her sick
parent, and is responsible for all household chores and meals. The demands of caring for a new baby
have left her exhausted and overwhelmed. She can barely find time to take a shower. As a member of
the internatal care group, she is eligible for assistance with some of these activities. If she desires, a
volunteer community health worker will assist her for a few hours monthly with light housework, cooking,
grocery shopping or other activities she requires.
At the end of the year, Mrs. Durham may be invited to receive additional training to become a mentor or
health advisor for other new mothers in her community. She will continue her group fitness twice a week
with other mothers who have finished the group care curriculum. She will connect, online with her Group
provider to chart her progress and address queries. Mrs. Durham’s provider will have individual follow up
with her within one year of finishing the group and again six months later.
What volume of services is associated with your alternative model of care?
What providers (both physician and non-physician) and community stakeholders would be
involved in delivery of your alternative model of care?
Approximately 5000 deliveries occur in Durham, Co, shared between Duke University and Durham
Regional hospitals. From DSR data, there were 19,739 unique deliveries between 2002 and 2009 and
2,970 (15%) had a subsequent delivery within 2-3 years (email Hongqiu Yang, Duke Biostatistician,
November 23, 2009). We anticipate reaching approximately 10% of the obstetric population in 2 years, or
approximately 500 postpartum women. Ideally, these women should live in the areas designated
geographically (Appendix D-H) as areas with the highest prevalence of these high -risk conditions. For
the initial phase of the study (first 4 months) we will recruit 4 groups of 15 women each.
In order to reach a target population, our plan is ambitious. Groups will occur monthly. After the initial 4
months, we will recruit 2 groups (15 women in each group) monthly. Each individual group will last 9
months. The maximum number of individual groups that will take place in a given month during the 2year period will be 16 in one month. In order to facilitate these groups, 4-5 group leaders (not fulltime) will
be needed.
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The individual provider sessions will occur in the previously described clinical settings. Groups may take
place during day or evenings. Ideally one location will provide the option of either time of day. For
providers, this type of timing may provide additional clinical flexibility. Approximately 4-5 fitness
instructors will assist participants. However, the NCCU athletic director (and MCH team member) will
direct coordination of volunteer instructors. Athletic students with community service requirements will
assist with maintaining these group fitness activities. As the project progresses, other volunteer
instructors will be recruited to participate in the program.
The program will need two Nutritionists to assist with group nutritional assessment, instruction during
group sessions, and individual assistance for patients with additional needs. Internatal Navigators (5) will
assist with coordination of 3-4 groups during a 2-year period. Approximately five Lay Health Advisors will
participate in this project.
The first phase of this model will focus on a three to six month aggressive community education
campaign to create awareness of the new model of care. Community stakeholders, LHAs, churches,
universities and no-cost social marketing tools will announce the program. Messages directing
communities how to access primary care will be streamed to targeted communities via the following
community accepted and utilized organizations:
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North Carolina Central University
Durham County Health Department Granny Group
B.E.S.T. Alliance for Breastfeeding
Lincoln Community Health Center
Durham County Health Department/Duke Centering program
Community Outreach programs (Baby Love, Healthily Durham Partnership, etc.)
Economic analysis – in current state of affairs, which bears the burden and what are the
economic implications of the proposed changes in the model of care?
What are the estimated incremental costs of delivering your alternative model of care assuming
that the primary connected care model is in place?
The proposed model of care will focus on improving preventable causes of maternal disease. Given what
is known about the costs of obesity and its co-morbidities—which is just one of the many illnesses
impacting pregnancy—and its co-morbidities, as well synergies that will result around these disease
states from the Connected Care model, one can comfortably postulate that a focus on improving
preventable causes of maternal disease will yield a financial benefit. We modeled the financial impact of
maternal obesity on excess delivery costs at Duke University Medical Center. Approximately 66% of the
pregnant women in our population were obese. Maternal obesity was associated with an increased risk
for gestational diabetes, preeclampsia, and cesarean sections. With increasing maternal obesity, the risk
for these complications increased. When non-obese (BMI<30) patients were compared obese (BMI>30),
there was a significant difference in cost with obese patients demonstrating higher average delivery cost
than non-obese (Small, 2010).
Given distribution of obesity in our population of 66%, every 5000 obese patients cost an additional
$161,700. For 50,000 patients, the additional cost would be $1,617,000 and for every, 100,000 patients
the additional cost would be $3,234,000. The reduction of maternal weight prior to the next delivery and
control of weight gain during pregnancy will not only improve both maternal and infant health but will
reduce expensive, and potentially life threatening conditions (Small, 2010).
Adverse outcomes of pregnancy impact nearly all aspects of healthcare and society. Given the long
term implication on physical, mental, and social health one can make the argument that the greatest
return on investment comes from preventing adverse outcomes of pregnancy. A detailed plan supporting
our model grounded of preconception care is outside the scope of this document, but data and
experiences that strongly support a context of healthcare that focuses on the interpartum period.
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The financial benefits are not only conceptual, as evidence for cost savings for such a model is
mounting. A 3-study meta-analysis demonstrated cost benefit, with one of the studies demonstrating a
theoretical savings of $1.60 in expensive maternal and neonatal hospitalization costs with a $1.00
expenditure on preconception care (Grosse, 2006). The second study, from a California retrospectively
matched cohort demonstrated a $5.19 cost saving from averted hospitalizations for every $1.00 spent in
preconception care when women received 2 preconception visits (the intervention) prior to beginning
regular prenatal care. The third work demonstrated a decrease in congenital malformations among
women who entered preconception programs compared to those in standard care, with 50% fewer
intensive care admissions for their infants. Overall, investments in preconception health may improve
overall health and therefore decrease the burden (and cost) of chronic disease, resulting in lower cost
(Phillips, 2008).
Implementation of our model will have some new costs. However, we believe that these costs will be
relatively incremental and minimal compared to the fixed costs associated with a connected care model
being proposed for Durham County and similar infrastructure needs in other DHI collaborative’ health
models. For example, the costs associated with the patient navigator program for a given DHI focus are
theoretically incremental and minimal as more disease states get managed through this route. The same
is true for information technology.
Additional key areas of need would include salary support for administrative support/project managers,
directly involved with this work. Additional costs would also include training and support for professional,
new centering pregnancy providers, nutritionists, instructors/educators, as wells as educational materials
needed to conduct groups. Durable medical equipment will be needed for sessions, as well, as a few
core pieces of mobile equipment for fitness sessions.
How do the health metrics identified by your team align with your proposed alternative model of
care?
The biologic markers of cardiovascular risk reduction, hypertension control, weight reduction, and
improved activity are measurable outcomes of this work. Long-term measures will include reduction in
low birth weight and infant mortality in subsequent pregnancies. These metrics, both short and long term,
will be achieved through the success of other metrics. The success of this model is dependent on the
engagement of the community and community resources with heath care providers. This engagement
involves linking to existing structures, which may help to address medical and nonmedical conditions that
may adversely impact health such as food insecurity. Support for community based, decentralized,
health resource utilization may improve the neighborhood level interventions for communities at highest
risk for the adverse outcomes. If this model decreases adverse outcomes for the highest risk women, it
will serve as a model of decreasing health disparities in adverse pregnancy outcomes. If women have
more resources in the internatal period, they may be less likely to utilize expensive emergency services.
What regulatory/policy changes (national/state/local) would facilitate your proposed alternative
model of care?
A successful model will be built upon the core principles of public health. Disease prevention and health
promotion however, are poorly reimbursed. Nevertheless, such interventions may provide the clinical
pillars for potential long-term cost savings (Phillips, 2008).
Nationally, Medicaid covers 41% of all deliveries and is, therefore the largest financier of maternity care
in the United States. For many poor women, however, this coverage ceases after 60 days postpartum.
Many of these women also bear a disproportionate burden of illness and risk for adverse birth outcomes
because of poverty (Phillips, 2008). In North Carolina, as in several other states, a family planning
waiver provides a limited package of interconception services to eligible women, but state officials have
recognized desirable improvements in such coverage. Much of the challenge in achieving fiscal
support for additional services comes from a limited evidence base and difficulty in demonstrating
budget neutrality necessary for federal funding. Standard guidelines for preconception coverage, based
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upon an evidence-based model, would provide a strong basis for policy change. Such guidelines may
include coverage of health education/risk assessment services, in both individualized settings with
primary care providers, as well as with ancillary providers of care services (e.g. group level nutrition
intervention/counseling).
In response to the child fatality task force’s recommendations for interconception care funding, the North
Carolina Legislature recently passed the following Bill aimed at reducing infant mortality and preterm
birth “Department of Health and Human Services, Division of Medical seek a Medicaid 1115 waiver or
implement other available Medicaid options to provide interconception coverage to low-income women
with incomes below one hundred eight-five percent (185%) of the federal poverty guidelines who have
given birth to a high-risk infant. A high-risk infant is defined as weighing less than 1500 grams, is born
less than 34 weeks gestation, is born with a congenital anomaly, or who has died within the first 28 days
of life. Interconception care shall be limited to two years following the birth of a high-risk infant, or until a
subsequent birth, whichever comes first. The Division is authorized to develop a benefit package to
improve interconception care to decrease poor birth outcomes in subsequent pregnancies. The Division
shall provide estimates of the cost savings from improved birth outcomes that will offset the cost of
providing Medicaid coverage to this“(www.ncga.state.nc.us/Sessions/2009/Bills/House/
accessed
December 1, 2009). The legislation presently resides in the appropriations committee. Implementation of
this policy would greatly facilitate adaptation for internatal care models of care, particularly for the large
population of women at risk with Medicaid insurance.
How could the proposed model of care be evaluated in terms of processes, impact, and
outcomes?
We will conduct three types of evaluation of the Internatal Care Program:
1. A process evaluation will take place 30 days from the initial enrollment of participants to the
Internatal Care Program. The process evaluation will assess the degree in which the initial
education and referral information was received and utilized by the participants.
2. An impact evaluation will take place at 60-day intervals from initial enrollment in the program to
assess the impact of the program on participants’ behavioral changes. We will assess increased
activity, stress management, diet modifications (low fat, low sodium, increased fruits and
vegetables), folic acid consumption, and medication compliance. We will also assess health care
utilization to evaluate whether participants utilize emergency services for non-urgent conditions.
3. Outcome Evaluation will take place one year from the initial enrollment in the Internatal Care
Program. Participants will be assessed on the long term outcome metrics such as: indictors of
weight reduction or maintenance, glucose control, blood pressure control, HDL/LDL at target,
decreased alcohol consumption, smoking cessation, diet modification, increased weekly exercise,
improved stress management, and overall adherence to her ‘reproductive life plan’. Long term
outcome evaluation will assess increases in inter pregnancy intervals, health care utilization, and
mostly importantly reduction in both maternal morbidity and low birth weight/infant mortality.
What are the critical components to the long-term sustainability of the proposed model of care?
The proposed model of internatal care utilizes a community-based participatory research (CBPR)
process. CBPR is a collaborative approach to research that equitably involves all partners in the
research process and recognizes the unique strengths that each brings (Israel, 1998). Our CBPR
process began with infant mortality, a research topic of importance to the community. Our intent with
CBPR is to transform research from a relationship where researchers act upon a community to answer a
research question to one where researchers work collaboratively with community members to define the
questions and methods, implement the research, disseminate the findings and apply them.
Our community members have become an integral part of the research team and researchers have
become further engaged in the activities of the community. Thus, the critical components to long-term
sustainability of our proposed model are the components that are also critical to sustaining a
community-based participatory research process. These include: creating of a project that comes from
the community versus one that is imposed by a funder, engaging in public relations to keep our
14
activities highly visible, building upon established activities and community assets, choosing an effort that
is based on a demonstrated community need, helping other organizations fulfill their mission, nurturing a
well-positioned advocate, and involving residents in the decision making so that the activities are relevant
and the residents have a long-term commitment to the effort. The components of the internatal care
model were based on community needs and assets. The proposed services of the internatal care model
will be delivered in the manner thought most feasible by community members, particularly those most
likely to need internatal care.
Other aspects of our process important to long-term sustainability are having some members of our team
focused on sustainability while others focus on the desired outcomes. While we are hopeful for
additional financial and resource support from Duke we will also look for opportunities among new
federal and state initiatives and try to obtain funding from within the community by trying to identify
people with financial resources. We will also seek to build additional relationships with funders through
philanthropies, corporations and grant making agencies while encouraging funders to increase the
proportion of funds dedicated to the prevention of infant mortality. An additional component of long-tern
sustainability includes monitoring our team's impact through the evaluation of the CBPR partnership and
the program implementation. Such an evaluation involves partners in the design and conduct of the
evaluations. Process evaluation will be used to monitor the health of the partnership. Process
evaluations can be done relatively simply and inexpensively by incorporating reflective discussions into
board meetings, periodic online anonymous surveys or annual face-to-face interviews with partners.
Process evaluation participants will also include women who have been a part of our program. We will
also conduct outcome evaluations to determine if the important factors affecting infant mortality and preterm delivery are reduced. To sustain the long-term support for our efforts in the community we will
share and disseminate our findings and successes with the community.
KEY ELEMENTS OF A CONNECTED CARE MODEL FOR SUCCESS OF PROPOSED TEAM MODEL OF CARE
What functions would your team want a CC model to contain?
A connected care model emphasizing internatal care would ideally encompass 4 functions: (1)
Community engagement; (2) Provision of services, defined as group and individual care; (3) Involvement
of key stakeholders including state and county agencies, nonprofit organizations, community
associations, the faith community, NCCU and Duke; (4) Coordination of services, staff, resources and
data.
How would workflow and processes ideally work within the CC model?
Women would be identified prior to leaving the hospital, and approached for full involvement in internatal
care by a hospital social worker, provider, or patient resource manager. If the patient is interested in
enrolling, an internatal navigator (IN) would be made aware of the initial contact and would contact the
patient before scheduling a visit within the first 2 weeks postpartum to provide support and perform
assessment. The patient would be offered participation in an internatal group with other women from the
same community. The internatal navigators would work with the patient’s internatal care provider to
develop a personal health map, encompassing self-care, patient education, diet, fitness, medical care
plan and contraception resources/family planning. Key metrics (height, weight, blood pressure, blood
glucose, and urinalysis) would be obtained at the time of encounters with lay health advisors, as well as
during group care sessions. These data would be recorded and shared with the primary health care and
OBGYN providers; no matter what setting she visits.
How can we ensure that Durham County residents and patients remain engaged in the Connected
Care system and the more formal health system where appropriate?
Maintaining an active relationship between the health community and Durham County residents is key to
the success of our model. This would occur through two main mechanisms. First, partnerships with
community agencies; other organizations such as churches, state and local agencies; and the medical
system (primary care and OB/GYN providers, community practices, DUMC and DRH) would be
facilitated by the internatal navigators (who have a presence in the community). These interactions
would provide a web of support and follow up for patients. Also, hosting regular screenings and
educational activities throughout the community will encourage regular participation in health activities
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and the health system. Second, mechanisms such as an integrated IT system enabling communication
between these institutions and patient access to medical data would allow for better follow up and build
patient confidence in the Connected Care model. Communication among providers and community
workers is essential to meeting the needs of the community.
We envision the following methods to maintain engagement with the community:
 A collaborative social marketing committee comprised of representatives from Durham County
Government, Duke University, Faith-Based Organizations, and Human Services to devise a
social marketing campaign to promote an Internatal service of care.
 Pilot community sites to offer medical and community support services for Internatal clients.
 Form and sustain an Internatal Advisory Council (including current members of the MCH—DHI
internatal team) that will monitor the progress, establish guidelines for services, and seek funding
for the continuation of services
Internatal Messages/ Social Marketing Campaign will be:
 Tailored to all so that messages will fit everyone
 Inclusive of older adults. Messages will encourage them to promote wellness in younger
generations. This approach with target potential ‘parenting mentors.’
 Take the focus off of pregnancy. Focus overall wellness instead of pregnancy. Use terminology
other than “preconception health”
 Duplicated in all settings for educational efforts
This model’s format will answer, “Where can I receive health care and feel comfortable?” Internatal
Social Marketing Committee and partnering organizations will create a feeling of trust and ownership for
residents thus creating a community’s new era in accessing community oriented primary health care.
How can we ensure that residents/patients have an opportunity to understand their health care
treatment options, as well as how their own behavioral choices affect their health outcomes?
Patients will have the opportunity to understand their options through discussions with the internatal
navigator, group care providers, medical care providers and access to online or print information. In
addition, the model, with both group and individualized support, is an effective model for not only
behavioral changes in pregnancy but also beyond pregnancy. Women will have health messages
presented and reinforced in the Centering model as well as by lay health advisors (Icovics, 2007). The
proposed use of health navigation and individualized health visits should improve patient understanding
of and adherence to health messages. The collaborative ‘life plans’ developed between women and
their primary providers, as well as the focus on connecting women with key community agencies and
supports will particularly allow the most vulnerable high risk women to focus on and improve their health
statuses.
How can we maximize the probability that residents/patients will adhere to the plans that are
agreed upon between providers and residents/patients?
A key mechanism for ensuring that patients understand their health treatment options and the effects of
their behavioral choices on health outcomes will be the involvement of the internatal navigator, our use of
the internatal group care model, and patient access to print and online information. Within the context of
this model, patients will be made aware of health treatment options (including but not limited to primary
care providers, the medical home, alternative sites of care, and lay health advisors). The group
internatal care model will present and reinforce these options in a way that is understandable and
acceptable to residents/patients. The strong patient education component of our model will help patients
to understand that their behavior (especially nutrition, exercise and smoking) is linked to their health
status and outcomes. Because a cornerstone of our approach will be emphasis on self-care,
residents/patients will have the opportunity to understand and directly take responsibility for their health
choices.
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How can we ensure that critical patient information (medications, allergies, etc.) is shared
efficiently across the multiple components of the CC system?
In order for critical patient information to be shared across the CC system, significant IT support
(personnel, hardware, and software) are required. Software is required that could interface with diverse
existing platforms and systems, for example, between DUMC systems (such as Browser and IDX) and
COACH, as well as the Lincoln Health Center server. Hardware (in the form of desktop computers in
office spaces) would serve as nodes in such a system. Rather than merging databases, a more fruitful
approach would be to allow access to data in different databases. Finally, in order to promote self-care
and empowerment, patients should have information on their metrics (“know your numbers”).
What information systems (functions) would your team want as part of the CC model?
The IT infrastructure should, over time, develop the following capabilities:
1. Record participants’ baseline metrics, and provider and navigator notes in real-time;
2. Interface with other IT platforms (e.g. COACH [LATCH]) so as to share data with organizations
and individuals involved in the “web of care”, including other DHI teams;
3. Enable women easy access to their metrics (“know your numbers”), including having their own
means of storing and charting their own progress in order to facilitate self-care;
4. Provide the capacity for patients to communicate with each other and providers as they progress
through the postpartum period (e.g. through a web portal).
What information does each component of the system need?
Individuals and organizations promoting community engagement (such as DHI groups) would need to
have data that could be used for social marketing, such as demographics, patients’ cultural preferences,
components of effective methods for reaching an audience, and tools to study the effectiveness of such
efforts. They would also need to assess their effectiveness in the community. Care providers need
access to patient clinical data across the “web of care”, as described above. They also need to be able to
communicate with each other, consultants, and health navigators and to document such communication.
They need a method for tracking referrals, laboratory studies, procedures and radiology. Finally, for
group care models, they would need to disseminate information to women in a group setting. Health
navigators need to be able to function as the “point people” in a connected care model. Because of
women’s complex needs in internatal care, navigators must have access to health information at multiple
levels, and be able to communicate with patients as well as multiple members of the “web of health”
including health providers, community agencies, and lay health workers. Residents/patients need to be
able to access their test results, health metrics, and information related to health maintenance.
How should that information be shared?
To protect patient confidentiality and privacy, sharing of patient level identifiable information should be
restricted to care providers and navigators, with navigators functioning as case managers. As noted
above, the latter individuals should access the requisite databases rather than using a merged database.
Residents/patients should have access to test results and health metrics to promote self-care, with such
information being stored in a separate format from detailed patient records. This would prevent
accidental disclosure or deliberate attempts by unauthorized individuals to access records.
Who are the stakeholders for this model in Durham County?
Key stakeholders for this model in Durham County have been identified in community outreach,
outpatient and inpatient care and coordination, financing, links to participating universities:
1. Community outreach stakeholders include the Durham County Department of Health, especially
through its lay health advisors and community health workers; El Centro; Partnership for a
Healthy Durham; the Durham Coalition; Alpha Kappa Alpha sorority; and the Durham Academy of
Medicine, Dentistry and Pharmacy;
2. Medical care stakeholders include nurse practitioners and physician assistants, midwives and
physicians practicing in the community, at free clinics (e.g., Good Samaritan) and at the Health
Department and Lincoln Community Health Center (outpatient) and hospitalists (at Durham
Regional and DUMC) (inpatient). Clinic, health center and health department administrators and
17
leadership are also key stakeholders, as are academic department administrators and leadership
who help allocate clinicians’ time. LATCH is an important stakeholder for coordination of care.
3. Financing stakeholders include Project Access of Durham County, NC Medicaid, sources of
charity care, drug companies and philanthropic organizations.
4. Participating university stakeholders include North Carolina Central University, University of
North Carolina at Chapel Hill, and Duke University.
18
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21
APPENDIX A – INFANT MORTALITY: DURHAM, NC 2003-05
CDC, 2005 PERIOD LINKED BIRTH/DEATH SET
22
APPENDIX B – LEADING CAUSES OF INFANT MORTALITY
PARTNERSHIP FOR A HEALTHY DURHAM, 2007
23
APPENDIX C – MODEL TRADITIONAL PRENATAL CARE VS. INTERNATAL CARE
Prenatal Care
Intranatal Care
(Birth)
TRADITIONAL
CARE
Conception
+/- Postnatal Care
Adverse
Maternal
Outcomes:
Adverse
Neonatal
Outcomes:
•Weight gain→obesity
•Diabetes
•HTN/preeclampsia
•depression
•LBW
•PTL
Prenatal Care
Intranatal Care
(Birth)
INTERNATAL
CARE
Conception
Postnatal Care
IMPROVE
Maternal
Outcomes:
IMPROVE
Neonatal
Outcomes:
•Weight gain→obesity
•Diabetes
•HTN/preeclampsia
•depression
•LBW
•PTL
24
APPENDIX D – PREECLAMPSIA/ECLAMPSIA DURHAM COUNTY 2007
25
APPENDIX E – MATERNAL OBESITY IN DURHAM COUNTY 2007
26
APPENDIX F – LOW BIRTH WEIGHT INFANTS IN DURHAM COUNTY 2007
27
APPENDIX G – MATERNAL HYPERTENSION DURHAM COUNTY 2007
28
APPENDIX H – MATERNAL DIABETES DURHAM COUNTY 2007
29
APPENDIX I – OUTCOME MEASURES
Outcome Measures
Number of Emergency Care visits for nonemergency conditions
- Weight Loss/Maintenance
- Breast feeding duration
- Increased Activity Level
- Folic acid consumption
--HgbA1c
--BP at target
Comparison of pre and post surveys regarding health, nutritional literacy, measures of social support, stress ,
knowledge of community resources
Rates of breastfeeding at hospital discharge, 6 weeks, 3 and 6 months postpartum
Immunization rates of infants in the first 3 months of life
6 week postpartum visits kept, completion of postpartum glucose tolerance test
Desire for and use of contraception at discharge, 3 and 6 months postpartum
Pregnancy intendedness with subsequent births, Interpregnancy interval of >12 months
Decrease in low birthweight, improvement in maternal health with subsequent birth
Decrease infant mortality
30
APPENDIX J – TEAM MEMBER DESCRIPTIONS
Sharon Baker, JD is Community Project Coordinator for the CHC. Ms. Baker has expertise in leading
focus groups in community organizations. She will work with Ms. McLaurin to develop and implement
community partnerships, including focus groups, analyze results and provide guidance as community
liaison.
Lottie Barnes, MPH, CHES is a Safety & Health Specialist with past research interest in radiation
exposure from medical devices with Duke Radiation Safety Division. She has experience in developing,
implementing and evaluating community education program with the Community Health Coalition. She
served as the Data Analysis Chair and assisted the project manager during the planning process.
Tammy Sinclair Bishop, RNC, MSN, Project Manager, is a Nursing Program Manager in the Duke
University Department of Obstetrics and Gynecology. She will advise and assist co-leaders in community
engaged research, organize and conduct surveys and focus groups, coordinate communication between
project team members, the DHI Oversight Committee and Technical Assistance Cores, and assist with
data collection, management and analysis.
Bobbie Brown, RN, MSN is Assistant Professor, NCCU School of Nursing. She has extensive
background in community nursing, community engagement and academic nursing. She will be
responsible for development of the Maternal-Child Health Intervention Group model for training
community health workers and heath navigators in interconceptional care and education. She will also
assist with model/curriculum development for nursing students on interconceptional care as well as
developing evaluation and research tools.
Haywood Brown, MD is the Roy T. Parker, MD Professor and Chair of the Department of Obstetrics
and Gynecology. Dr. Brown is past president of the Society for Maternal Fetal Medicine. He is a
consultant for the HRSA Interconceptional Care Learning Module, a two year project designed to
improve pregnancy outcomes and long term health by focusing on interconceptional (internatal) care.
Dr. Brown is committed to the care of women at high risk for adverse pregnancy outcomes particularly
the disadvantaged and his research focus is in perinatal health disparities. Dr. Brown is nationally
recognized for his contributions to medical education.
Monique Chireau, MD MPH, Co-Investigator, Co-Team Leader. Dr. Chireau is an Assistant Professor
with extensive research and clinical experience working with underserved women. She will assist in
coordination of project activities, design, and management. She will, along with the Co-Team Leaders,
be responsible for IRB preparation, focus group/survey design, implementation, model development, and
manuscript preparation.
Tamera Coyne-Beasley, MD, MPH, Community Co-Team Leader, is Associate Professor of Pediatrics
and Internal Medicine at UNC-Chapel Hill, and has extensive clinical, research and policy experience
related to community issues. She will be responsible for assisting with coordination and collaboration
with community based groups and stakeholders, model development, development of an evaluation tool
for newborns, data analysis, and manuscript preparation.
Kim Dau, RN, CNM, MSN, Consultant, is a Spanish speaking certified nurse midwife and coordinator of
the Centering Pregnancy Program (group prenatal care) at Durham County Health Department. She will
help to develop the model for internatal care, as well as help in liaisons between the team and the health
department’s Centering program.
Janeen Gammage, BS, MSLS is a member of Alpha Kappa Alpha Sorority, which is volunteering time
and space in their community center, Ivy Community Center, for meetings of the internatal care team.
31
She will also participate in project support and has identified this project as a volunteer activity for the
sorority. She will support mother-granny mentors and as links to community services
Sue Guptil, MSN is the Director of Nursing for the Durham County Health Department and has broad
background in public health nursing. She will be responsible for coordination with Health Department
ancillary services to be included in the Maternal-Child Health Intervention Group model (lay advisors,
granny mentors, Durham connect, and prenatal services such as Baby Love). She will also assist with
the development of a program for interconceptional care, which can be utilized at the Durham County
Health Department’s pregnancy care center.
William Hackney, Administrative Assistant, Duke University Department of Obstetrics and
Gynecology. He will assist with communications and administrative support.
Elaine Hart-Brothers, MD, MPH is an internist with extensive experience working in the Durham
community, as well as strong background in community and minority health. She will be responsible for
helping develop the Maternal-Child Health Intervention Group care model, assisting with survey
development, and coordination of town hall meetings (i.e. between agencies and organizations). She will
also have organizational responsibility for administration of CHC activities related to the current grant.
Jimmie Hawkins, Midi., is pastor of Covenant Presbyterian Church in Durham and has extensive
experience working within Durham and with the Durham faith-based community. He will be responsible
for coordination of activities as well as assisting with development and administration of survey materials
with and for the faith based community. He will also assist in development of components of the
Maternal-Child Health Intervention Group care model that address women’s spiritual needs.
Diane Holditch-Davis, RN, PhD, Co-Investigator. Dr. Holdritch-Davis is a Professor with extensive
research experience examining maternal-child interaction and development from cultural, biologic, and
social perspectives in preterm and low birthweight pregnancies. She will assist in manuscript preparation,
survey instrument development for focus groups, interviews, analysis of questionnaires, model
development, and application of this for nursing curricula and nursing research.
Elizabeth Jensen, MPH Candidate, serves as the Project Coordinator for the Durham Breastfeeding
Education and Support Team (B.E.S.T.) for Babies Alliance, a collaborative effort between the
Community Health Coalition the UNC Gillings School of Global Public Health. She is also a graduate
student at the University of North Carolina at Chapel Hill in the Department of Maternal and Child Health.
Ms. Jensen has extensive experience working on public health initiatives that serve the maternal and
child health population, including a managing a three year, state-wide initiative to increase preconception
health in Florida.
William Lawrence, MD, Consultant, Wake County Medical Director, Duke Primary Care, and former
director of North Carolina Medicaid. Dr. Lawrence’s interests include novel approaches to improve health
literacy, including cost benefit analysis. Dr. Lawrence is a pediatrician who will provide consultation
regarding project implications for neonatal outcomes.
Sue McLaurin, M.Ed., PT, Community Co-Team leader, is Community Principal Investigator for the
CHC and has significant experience with developing and implementing community partnerships,
educational projects and technology assessment. She will assist with development of focus group
surveys, conduct of focus groups and analysis of data/responses. She will also participate in the
development of instruments for town hall meetings and surveys (for community members, the pastoral
community, and community health workers).
32
Evelyn Morrisey, BS, LD/RD, D.Min. is a member of Alpha Kappa Alpha Sorority, which is volunteering
time and space in their community center, Ivy Community Center, for meetings of the internatal care
team. She will also participate in project support and has identified this project as a volunteer activity for
the sorority. She will support mother-granny mentors and as links to community services
Sarah Nahm, MPH, RD, LDN is a bilingual public health nutritionist with the Durham County Department
of Health. Ms. Nahm has an extensive background in program development for underserved women.
She will be responsible for development of an intervention to improve interconceptional nutrition in the
Maternal-Child Health Intervention Group model, and to work with stakeholders to develop and apply the
Maternal-Child Health Intervention Group model for the Latino community.
Renee Parks-Bryant, Health Education Specialist, Program Coordinator for the Infant Mortality
Reduction Committee. Ms. Parks-Bryant has extensive experience in developing and implementing lay
health advisor models. She is a lay health advisor for the Durham County Health Department. She will
help to develop a health education program for participants and will serve as a liaison between the lay
health workers and study participants.
Rachel Peragallo, MD. Dr. Peragallo is a chief resident in Obstetrics and Gynecology. She has
experience with qualitative research and in developing community partnerships with academic
institutions both locally and internationally. She will assist conducting and analyzing qualitative research
as well as manuscript preparation.
Rhonda Reaves, Financial Analyst II, Duke University, Department of Obstetrics and GynecologyOffice of Research Support. Ms. Reaves has over 20 years experience in grants and contract
administration, budget and financial analysis, and special project coordination. She will provide grant
administration support.
Jessica Simo, MHA is the Network Coordinator for the Durham Community Health Network, a Durhambased Medicaid care management program. She works with many community stakeholders to address
the healthcare needs of Medicaid recipients. She will provide support to this initiative through linking her
care management team with other resources to strengthen interconception health education and support
for Durham Medicaid recipients.
Maria J Small, MD MPH, Co-Investigator, Co-Team Leader. Dr. Small is an Assistant Professor with
interest in hypertensive disease in pregnancy, adverse maternal outcomes, and group prenatal care. She
has expertise in Maternal Fetal Medicine and designing care for women with high risk obstetrical
conditions. She will serve as the team contact and liaison and will assist in coordination of all team
activities and collaborations with other community groups. Dr. Small, along with the Co-Team Leaders,
will be responsible for IRB preparation, focus group/survey design, implementation, model development,
and manuscript preparation.
Rosa Small, BS, MSLS, is a member of Alpha Kappa Alpha Sorority, which is volunteering time and
space in their community center, Ivy Community Center, for meetings of the internatal care team. She
will also participate in project support and has identified this project as a volunteer activity for the sorority.
She will support mother-granny mentors and as links to community services.
Geeta Swamy, MD MSS, Co-Investigator. Dr. Swamy is an Assistant Professor and her research
includes use of geospatial mapping to study health disparities in obstetrics and developing vaccine
intervention programs for pregnant and post partum women. She will assist in model development,
33
data interpretation, literature review, grant writing, and manuscript preparation.
Kevin Thomas, MD, Consultant, Cardiology. Dr. Thomas is an Assistant Professor and his research
interests include racial disparities in cardiovascular disease. He will assist in developing appropriate
short and long term assessment of cardiovascular disease reduction among the at risk population
utilizing a quality improvement paradigm. Dr. Thomas will also assist in manuscript preparation and
development of agenda/survey materials for possible overlapping community town hall meeting in African
American Community.
Ingrid Wicker-McCree, Ed.D. is Athletic Director, NCCU. She brings expertise in models for community
health through athletics and will be responsible for developing a care and education model involving
student athletes as role models and assistants in interconceptional exercise and physical activity
programs.
Elizabeth Woods, MA, MPH, director of Soul Food For Your Baby, a project that aims to increase
breastfeeding among African Americans in South Los Angeles. This year she also joined forces as the
Community Health Liaison with the Durham Breastfeeding Education and Support Team (B.E.S.T.) for
Babies Alliance, a collaborative effort between the Community Health Coalition in Durham and the UNC
Gillings School of Global Public Health. Before earning her MPH, Ms. Woods worked in communications
for a Los Angeles-based homeless agency and as a copy editor for daily newspapers in San Diego and
L.A. counties. She has an MPH with an emphasis in Community Health Sciences from UCLA and an MA
in international development studies from the University of East Anglia, Norwich, UK.
34
APPENDIX K – CLINICALLY IMPORTANT AREAS OF PRECONCEPTION CARE CONTENT
1. Immunizations
2. Infectious Disease
3. Medical conditions
4. Psychosocial situations
5. Medications
6. Reproductive History (e.g. prior low birth weight infant)
7. Genetics and genomics
8. Psychiatric conditions
9. Parental Exposures
10. Environmental Exposures
11. Special Populations (immigrant/refugee populations, cancer survivors)
12. Men (preparation for fatherhood, supportive relationships, genetic conditions)
(JOHNSON [CDC], 2006)
35
APPENDIX L – TRADITIONAL PRENATAL CARE VS. CENTERING PREGNANCY® GROUP
PRENATAL CARE
Traditional Prenatal Care Vs. Centering Pregnancy® Group Prenatal Care
Traditional
Delivery of care
1. Accepted model of prenatal care using one-to-one
exam room visits
2. Care is provided by a credentialed prenatal provider
Content of care
3. Variable continuity of provider throughout pregnancy
4. Physical assessment completed inside an
examination room by a provider
5. Education is provider-dependent and may be
random based on time available for education and/or
response to patient- initiated queries
6. Few opportunities for women to interact socially with
other pregnant women
7. Care is focused on medical outcomes and
recommended testing
Patient access to/involvement in
care
Time spent by providers and
patients
8. Prenatal care records are maintained by the provider
and not shared with the patient unless requested
9. Provider schedule determines patient appointment
dates and times.
10. Patient services are often fragmented (e.g.,
smoking cessation and nutrition counseling, WIC, labor
preparation)
11. Limited opportunity for women to have contact with
other women after delivery
12. Variable waiting time
13. May be difficult to adapt care to accommodate
cultural issues
14. Providers may find the provision of prenatal care to
be repetitive, and often lack sufficient time to go into
more detail regarding specific patient questions or
concerns
15. Average visit time is limited by provider schedule
Administration/scheduling
16. Efficiency marked by scheduling of patients at 1015 minute intervals
Provider/resident/student
education
17. Student education is limited by exam room space
and time constraints
Group Care
1. Prenatal care provided within the group space (community or
conference room)
2. Care is provided through a partnership of a credentialed
provider and pregnant woman
3. Continuity of care from a single provider
4. Patient participation in physical assessment (e.g., blood
pressure, weight) and documentation. Fundal height and heart
rate monitoring occur in group space. If required, health
concerns that require private consultation and cervical
examinations are conducted in ancillary visits in a private
examination room.
5. Education runs throughout the ten sessions with trained
providers and structured materials. Self-assessment sheets at
sessions provide continuous feedback
6. Opportunities for community building are present throughout
prenatal/postpartum period.
7. Care is focused on health outcomes and personal
empowerment. Testing such as blood draw can be done in
group setting
8. Women contribute data to their own record by performing
their weight and blood pressure as well as documentation.
They are encouraged to keep copies of their progress for their
personal records. Transparency of the medical chart should
contribute to increased safety.
9. Schedule of group visits is available at first session which
occurs at approximately 16 weeks
10. Group provides “one stop shopping” with all services
available within the group, providing services more efficiently
11. Community building throughout pregnancy often leads to
ongoing support postpartum
12. All care, education, and support take place within the twohour time period; no waiting room
13. Group can provide a setting that is supportive of cultural and
language differences
14. Groups minimize repetition and permit sufficient time for
more in-depth discussion
15. Total provider/patient time throughout pregnancy is
approximately 20 hours
16. 8-10 women can receive total care within a 2-hour period in
a conference or community room. This allows examination
rooms to be used for other purposes.
17. Students and preceptors work together within the group,
incorporating student education and direct supervision
(From Icovics, 2007 with permission)
36
APPENDIX M – INTERNATAL CARE MODEL
INTERNATAL “Group” CARE MODEL
CNMs, MDs, RNs
(Duke-NCCU)
“LIFE COURSE”
Social
support
Preconception
Smoking
Obesity
DM
HTN
OUTCOMES
Health
education
Community Engagement
Faith based centers
Community centers
Neighborhood Locations
Life Events
Allostatic loac
Chronic stress
Neighborhood stress
Nutrition & Fitness
Empowerment
Improve Maternal Health
Weight loss/maintenance, Hgb A1c
Folate Risk reduction (smoking)
Improve Child Health
LBW, Infant Mortality
Low birth weight
Navigators/LHA
Individual Plan with PCP in Postnatal Period
37
APPENDIX N – GROUP INTERNATAL CARE CORE CURRICULUM
Group Internatal Care Core Curriculum
Group 1: Basic Introduction—
-Baseline Health Metrics—understanding personal health and postpartum health
- Develop a Personal Health “Plan”/Family Planning
- Health Navigation Resources
Group 2: Nutritional education including food label literacy, diabetic diets
Group 3: Mental health: Postpartum Depression, Spirituality, Relaxation Techniques/Hypertension
Group 4: Caring for your new infant. Breastfeeding. Immunizations.
Group 5: Family Planning
Group 6: Parenting
Group 7: HIV/AIDS, Sexuality
Group 8: Partner Violence
Group 9: Back to work/school: Housing, Social Services, Community services
Group 10: Folic Acid, Medications, Substance Abuse
38

the maternal-child health intervention group (mch

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