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Lois McCloskey DrPH, Penny Liu ScD MPH, Xandra Negron BA, Rosie Munoz-Lopez MPH,

Outreach and Outcome: Does the Boston Healthy Start Initiative’s Interconception Care Model Make a Difference?. Lois McCloskey DrPH, Penny Liu ScD MPH, Xandra Negron BA, Rosie Munoz-Lopez MPH, Snehal Shah MD, MPH, Barbara Ferrer PhD, MPH, MEd. Background. Boston Infant Mortality

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Lois McCloskey DrPH, Penny Liu ScD MPH, Xandra Negron BA, Rosie Munoz-Lopez MPH,

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  1. Outreach and Outcome: Does the Boston Healthy Start Initiative’s Interconception Care Model Make a Difference? Lois McCloskey DrPH, Penny Liu ScD MPH, Xandra Negron BA, Rosie Munoz-Lopez MPH, Snehal Shah MD, MPH, Barbara Ferrer PhD, MPH, MEd

  2. Background Boston Infant Mortality Boston Healthy Start Initiative

  3. Infant Mortality in Boston • Black infants 3-4 times more likely than white infants to die in first year of life and to be born at low weight • Black IMR 13.2: White IMR 3.6 (2006) • Highest proportion of black infant deaths and highest rates in Project Area in 1990’s • Black IMR in Project Area: 11.5 (2002-06) • Despite slight improvements in black IMR, disparity WIDENS

  4. Boston Healthy Start Initiative (BHSI) • Boston an original HS site from 1992 • Housed within Boston Public Health Commission • Emphasizes elimination of racial disparity and serves only black women (self identified) in project area • Includes African American, Haitian, Dominican women • Focus on most vulnerable, e.g. homeless, substance users • Funds network of 8 health centers and 5 community-based agencies • Each provides outreach and case management services to women and their infants from pregnancy until child’s 2nd birthday.

  5. BHSI Model: Outreach and Recruitment • Community Consortium (450 members) meets monthly—word of mouth • Partnerships with city-wide programs • “Healthy Baby/Child” (women’s circles) • “Father Friendly” • 1-800 #

  6. BHSI Model • Philosophy • Strength and risk-based care • Sustain health in interconception period through: • Connectivity to health care of all kinds • “Surround services” to reduce social isolation and support wellness • All of this will contribute to improved birth outcomes, esp. among black women at highest risk • Assessment • Guided by Women’s Health Questionnaire • holistic assessment for self and provider • Risks and strengths: depression (Beck’s), smoking, alcohol and substance use, domestic violence, housing/homelessness, weight, family and social supports and relations

  7. BHSI Model: Interconception Care • Case management assures: • Use of prenatal and postpartum care • Medical home: connection to primary care • Oral health • Mental health • Family planning • Case manager provides: • Health education • Advocacy • Social supports and referrals (e.g. housing,domestic violence, nutrition)

  8. BHSI Model: Case Management • Structural Characteristics(M..Issel et al, forthcoming) • Staff mix: RNs, SWers, and paraprofessional case managers. At each site: • .5 RN • .2 SW • 2 case managers (average case load=20) • Source and timing of referral in: during pregnancy but how and when varies by site • Integration with PNC: yes in clinical sites, no in community agencies • Setting: 2 home visits per quarter plus clinic and community visits

  9. Our Study Design and Data Sources Analytic Methods Findings

  10. Evaluation Questions • Does BHSI improve the likelihood that clients receive early and adequate prenatal care and give birth to healthy babies? • How do BHSI clients compare to their counterparts in the Project Area with respect to prenatal care use and birth outcomes? • What would you expect to find?

  11. Study Design and Data Sources • Retrospective cohort study • First known study to link HSI data to vital records • Data Sources • BHSI program data 2001-2005 (intake only) • Massachusetts vitals records 2001-2005 • Birth file • Linked birth-death file • Fetal death file • Comparison group: live births or fetal deaths to black women who lived in the BHSI project area and gave birth 2001-2005

  12. Data Linking Process(Deterministic Matching)

  13. Study Population

  14. Variables • Exposure:BHSI participation status • Socio-demographic characteristics: mother’s age, country of origin, marital status, educational attainment, health insurance for prenatal care, plurality, parity, gravidity • Clinical characteristics: smoking status during pregnancy, chronic hypertension, pregnancy-induced hypertension, gestational diabetes, seizure disorder, previous preterm birth, small for gestational age, method of delivery, complications of delivery, baby’s sex

  15. Variables • Outcomes • Use of prenatal care • Timing: <= 4 months gestation • Adequacy: Inadequate or Intermediate (Kotelchuck Index) • Birth outcomes • Early (< 32 wks) • Low weight (< 1500 gms) • Intrauterine growth restriction (BW < 10th percentile at GA)* • Infant or fetal death * (Oken et al 2003) [Also available: breastfeeding at birth, maternal weight gain]

  16. Analytic Methods • Bivariate analyses • Association between BHSI status and covariates/ outcomes and covariates (chi-square statistics) • Association between BHSI status and outcomes (crude RR’s and 95% CI’s) • Multivariate analyses • Association between BHSI status and outcomes with adjustment for significant covariates (adjusted RR’s and 95% CI’s) • Poisson regression model with a robust error variance (McNutt et al, 2003) • Stratified analysis to explore potential confounding and interactions

  17. Results

  18. Social and clinical riskBHSI v. non-BHSI • BHSI infants were significantly* more likely to be born to mothers who were: • Teenagers (26% vs. 16%) • Foreign born (46% vs. 39%) • Unmarried (80% vs. 66%) • < High school educated (31% vs. 15%) • Publicly insured (84% vs. 63%) • Nulliparous (47% vs. 41%) • Smokers during pregnancy (8% vs. 6%) • BHSI infants were significantly* less likely to be born to mothers: • With one or more clinical risk factors for this pregnancy (9% vs. 13%) * P < 0.05

  19. Entry of prenatal care ≤ 4th month of gestation Crude RR= 0.99, 95% CI= 0.96-1.01 % N= 1,236 N= 8,659

  20. Entry of prenatal care ≤ 4th month of gestation(predicted values) Adjusted RR= 1.04, 95% CI= 1.01-1.07 %

  21. Entry of prenatal care ≤ 4th month of gestationHealth insurance modifies effect of program on prenatal care entry* P < 0.05 P < 0.05 Non-BHSI BHSI BHSI Non-BHSI * Health insurance not associated with prenatal care adequacy in this population

  22. Intermediate or inadequate prenatal care use* Crude RR= 1.13, 95% CI= 1.02-1.26 % N= 1,217 N= 8,569 • Based on Kotelchuck Index (Kotelchuck, 1994)

  23. Inadequate or intermediate adequate PNC (predicted values) Adjusted RR= 0.86, 95% CI= 0.78-0.96 %

  24. Inadequate or intermediate adequate PNCHealth insurance modifies effect of program on prenatal care adequacy* P < 0.05 Non-BHSI BHSI P < 0.05 BHSI Non-BHSI * Health insurance not associated with prenatal care adequacy in this population

  25. Length of gestation < 32 weeks Adjusted RR= 0.47, 95% CI= 0.29-0.76 [Crude RR= 0.41, 95% CI= 0.25-0.65] % N= 1,255 N= 8,869

  26. Birth weight < 1500 grams Adjusted RR= 0.71, 95% CI= 0.47-1.07 [Crude RR= 0.62, 95% CI= 0.42-0.94] % N= 1,255 N= 8,852

  27. Intrauterine growth restriction (IUGR)* Adjusted RR= 0.95, 95% CI= 0.79-1.13 [Crude RR= 1.01, 95% CI= 0.85-1.20] % N= 1,255 N= 8,852 * Having a birth weight <10th percentile at a given gestational age for non-Hispanic black infants (Oken et al., 2003)

  28. LBW, preterm birth, IUGR, or fetal/infant death Adjusted RR= 0.91, 95% CI= 0.80-1.03 [Crude RR= 0.93, 95% CI= 0.82-1.07] % N= 1,255 N= 8,872

  29. Summary of Findings • Recruitment: Mixed bag • Low penetration in project area (10-14%) • Successful recruitment of women at highest social risk • Lower clinical risk among BHSI clients appropriate in light of shift to less intensive clinical case management • Access to prenatal care: Excellent and more to do • BHSI increased early entry into prenatal care and decreased less than adequate care • Gains seen only for women with public or no insurance, not for privately insured

  30. Summary of Findings • Birth Outcomes: Impact but limited • BHSI participation associated with decreased risk for very preterm birth (after risk adjustment) and very low weight (before risk adjustment) • Could reflect lower clinical risk of BHSI clients and/or • Impact of the program on the birth outcome most associated with stress related to high social and environmental risk • However, timing of entry into program unknown • BHSI participation NOT associated with decreased risk for restricted growth or our composite measure of “bad outcome”

  31. Our Findings In Context • Limitations of Study • Questionable validity of vital records data on risk factors, esp. clinical risks • Unable to measure exposure to other interventions in client and non-client group (e.g. city-wide HBHC) • Unable to link to BHSI program data • “dose” of services • content of services • intermediate outcomes, e.g. “medical home”, resolution of mental health and social risk • No information on longer term effects to reflect interconception care model, e.g. subsequent pregnancies and women’s health over time

  32. Our Findings in Context • Our findings consistent with prior studies on pregnancy-related case management (M. Issel et al forthcoming) • Most show significant positive program effect on prenatal care use • Some show positive effect on birth weight • Clearest evidence for nurse case management • (Olds D et al 1986, 1988, 1993, 1997) • Newest evidence favors cognitive behavioral models of PCM to interrupt cycle of risk (El-Mohandes AAE et al 2008)

  33. Take Home Messages So Far • Program • You ARE making a difference…..AND • Intensify OUTREACH to recruit more women in project area • Dig deep into neighborhoods, housing developments • Restore capacity for focus on CLINICAL high risk to maximize ability to intervene in social stress and clinical pathway • Add RN capacity or partner closely with other programs with clinical focus • Apply success for PNC to PP care and “medical home” • Special initiative to engage women with non-traditional risks • Working women, women with private health insurance!

  34. Next Steps for BHSI Evaluation • “Efforts to Outcomes” • Simplified and systematic real time data system to track program activities and outcomes • Will allow us to analyze social risks, referrals and resolutions (domestic violence, housing, nutrition, family planning) • Will allow us to track women’s connection to a medical home, prenatal care, postpartum care, mental and oral health care • BHSI data and PELL data linked • Will allow us to follow women and children (services and outcomes) over time and across pregnancies and births

  35. Conclusions • BHSI is a critical part of Boston’s WHOLE strategy to be an MCH organization that works upstream and downstream for women and families-- • Life course perspective • Systems approach • Policy change • By digging deeper and partnering wider BHSI can make a bigger difference for Black women and infants in Boston

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