Cindy Engler RN, MPH Beth Buxton-Carter, L.C.S.W. funded by the Maternal and Child Health Bureau

1. The Preconceptional Screening and Assessment Project: A Model to Address Behavioral Risk for Women of Reproductive Age in Primary Care Cindy Engler RN, MPH Beth Buxton-Carter, L.C.S.W. funded by the Maternal and Child Health Bureau

2. Overview • Goals and objectives • Background and rationale • Development of the tool • Feedback: Behavioral Experts, Provider, Consumer • Findings • Next steps

3. PSAP Goal: Improve the health of reproductive age women • Tool • Multiple risk assessment in single tool • Brief • Culturally appropriate • Process • Link screening to assessment, education and intervention • Enhanced capacity • Role of primary care provider • Replicable in diverse settings • Collaboration with Boston PHC and Mass DPH

4. Why screen for behavioral risks? • 20.7% of women ages 18-30, and 21.4% of women ages 31-45 reported they felt sad/blue/depressed for > two weeks • Twice as many Black women than White women reported poor mental health

5. Why Screen? • > 1in 5 adult women of reproductive age reported binge drinking w/in last month • 26% (vs. 10%) female students who used alcohol w/in last month report abuse by date • BIMR review – 25% reported being abused by their partners during pregnancy • 44% reported repeated unintended pregnancies often preceded by abuse

6. Why screen in Primary Care? • Safety-net/pivotal point of health care • Long term relationship • Integrated with range of health-related activities • Opportunities for early intervention

7. The sites • Site 1 • 3 areas or practice – Adult, Adolescent and Women’s Health • Latina, African-American, African, Non-Hispanic White • Site 2 • Family practice model • Latina, Southeast and South Asian, Eastern European, Brazilian, Cape Verdean • Both sites • Multiple screening tools in use • Variation in screening practice among providers • Challenges in linkage between screening, referrals and follow-up

8. Tool Development/Feedback • Screening Working Group – “experts” • Project Advisory Committee • Focus Groups of consumers • Provider Surveys and Meetings

9. Feedback loop Screening working group Community Review existing tools Focus groups Recommend questions, language Project advisory cmte Tool development Funder/Grantees Review questions, language BPHC/DPH Review feedback, results Patients Refine tool Providers Needs assessment Assess values & needs Focus groups Trainings Feedback

10. Challenges • “Cultural differences” • Consultants – providers • DV-s/a-depression • Buy-in • Time constraints in primary care • Capacity constraints in mental health • Defining boundaries between screening, assessment and intervention • “What do we do when someone screens positive??”

11. Provider Feedback • Time – as little as possible • The provider should not do the screening • Offends people from different cultural backgrounds • We already do this – we don’t need a script • We have no resources/capacity – don’t generate expectations that can’t be met • Won’t work with all cultural groups

12. PAC Feedback • Routine screening is not being done • There is a need to incorporate a brief screening tool into routine primary care • Trust/relationship is the key • Routine screening for depression helps reduce stigma “I want to be treated like a whole person”

13. PAC Feedback • Ideal if provider can do the screening – strong message about importance • Listen! Providers tend to hear the answers they want • Explore cultural context the behavior takes place in • All patients should receive some education – regardless of screening results

14. Focus Groups - General Feedback • Agreement that questions should be asked in primary care • Communication skills and relationship between provider and patient are key • Repeating same questions feels like “trick” to get positive response • State upfront – everyone is asked, and stress confidentiality

15. Focus Groups: Depression • Depression questions are clear, easy to understand • Non-judgmental: “When things in life are difficult” – takes responsibility off of woman • Opens a door, demonstrates interest • Rarely asked about depression- “Don’t ask, won’t tell”

16. Focus Groups: Alcohol/SA • Fear: admitting problem, legal repercussions • Need to ask in non-judgmental way • Negative response to questions about family and friends • Reframe as a common/direct medical question • Don’t expect honest response

17. Focus Groups: Domestic Violence • Important to ask, and difficult to answer • Don’t include too much…include everything • Start with questions on safety/emotional abuse, end with questions on physical violence • Questions about non-consensual sex with partner and control most controversial questions

18. Findings • Site 1 Pilot began September 24, 2004 • Site 2 Pilot began October 19, 2004 Based on approximately 1600 Women

19. Findings - depression • Baseline rates (by chart review) • 12% • PSAP rates • 23% any risk of depression • 14% Mild-moderate (score 3-5) • 9% Severe (score > 5)

20. Findings –Substance use • Baseline rates (by chart review) • 3% substance or alcohol abuse • PSAP rates • 36% any use English speaking • 22% any use Spanish speaking

21. Findings –Domestic Violence • Baseline rates (by chart review) • 2% history or current • PSAP rates • 14% history or current

22. Any positive screen • Site 1 44.3% • Site 2 52.4% • Combined 46.3%

23. Revised Tool

24. Lessons learned: • The tool • It works • It is acceptable to patients and community • It presents challenges to providers • The process of implementation • Parallel to other areas of questioning and assessment in primary care • Providers need efficient access to resources and referrals

25. What we learned… • We’re on the right track • Multiple risk screening is needed for reproductive age women • Screening tools needed for all ages, genders in primary care • Culture change in health practices take time • Patients accept change more readily than providers • Barriers must be continually assessed, acknowledged and addressed

26. Closing the Loop • Improve access to resources and referrals • Staff training – bringing women’s voices/experiences into their training • Pilot test role of case manager/advocate in all domains of screening • Enhance systems of feedback to providers

27. Mental Health Case Manager • Supported by BHSI • Supervised by Human Services/Mental Health • Sits in Primary Care • Performs screening prior to PE • Provides education and resources for all women • Regular communication with PCP

28. Case Manager role • Introduces self as primary care team member • Normalization/education of behavioral health in primary care • Offers brochure, business card • Able to see patient same day or quick f/u appt. convenient for patient • Tracks/follow up

29. Screens • 164 women screened • 43% (70/164) screened positive for some behavioral risk • 36% (55/164) positive risk for depression • 3% (5/164) positive for suicidal ideation 26% (18/70) any etoh/substance use • 14% (10/70) any domestic violence

30. What works… • Women are comfortable with case manager • Personal connection with easy access • Strong relationship with primary care and human services/mental health

31. Challenges… • Providers want to refer everyone who needs resources to the case manager • Start up takes more time – new role • More support needed for case manager than for primary care providers doing screening

32. Sustainability • OMH Funding: Increasing linguistic capacity • Integrate into existing team and forms • DPH role

33. Acknowledgements • Providers and staff at the three community health centers • Members of the Project Advisory Committee • All of the women in the community who participated in focus groups • Dr. Barbara Gottlieb • Massachusetts Department of Public Health • Boston Healthy Start Initiative • HRSA/Maternal and Child Health Bureau

34. Contact Information:Cindy Engler, RN, MPHBoston Public Health Commission1010 Massachusetts AvenueBoston, MA. 02118 cengler@bphc.org