Nancy Byatt, DO, MBA Liz Friedman, MFA Linda Jablonski, RNC, MSN

Transcription

1 Nancy Byatt, DO, MBA Liz Friedman, MFA Linda Jablonski, RNC, MSN

2 Impact of Perinatal Mood Disorders (PMD) on mothers and children Barriers to Care and Treatment Intervention Models Community-Based Perinatal Support Model Component Overview case study and results

3 Woman Fetus Infant Child Family

4 Up to 20% of women during pregnancy 10-15% of women the postpartum period 25% of women pregnant in the past year meet criteria for a psychiatric diagnosis

5 Maternal depression can lead to Low birth weight Preterm delivery Cognitive delays Behavioral problems Poor maternal health behaviors Maternal substance abuse Maternal suicide

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7 Untreated Women

8 Detection Assessment Engagement Treatment Symptom Improvement Improved Outcomes (daily functioning, parenting, well-being, quality of life, health, offspring health, relationships, family, prognosis)

9 Individual-level barriers Provider-level barriers Systems-level barriers

10 Stigma Misconceptions Lack of understanding Fear of failing as a mother

11 Four 90 minute focus groups Each group had 8 to 10 mothers Analysis: Verbatim transcripts analyzed qualitatively to identify themes

12 Individual-level Provider-level Systems-level

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18 Individual-level Provider-level Systems-level

19 Perceive barriers Support screening but need guidance Lack of adequate guidance, follow up and referral sources Report inadequate mental health training

20 Four 90 minute focus groups Each group had 8 to 10 providers/staff Analysis: Verbatim transcripts analyzed qualitatively to identify themes

21 Shame Stigma Fear of losing parental rights

22 Inadequate training Limited mental health resources Discomfort

23 Community-Based Perinatal Support Model

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25 Limited training among mental health providers OB and mental health care not integrated Lack of collaboration with mental health providers

26 Psychoeducation Destigmatize Positive feedback from provider

27 Training Structured screening and referral Provider confidence

28 Training for mental health providers Integration of mental health and obstetric care Immediate back up from mental health providers

29 PES Perinatal Emotional Spectrum PEC PECr Perinatal Emotional Complications Perinatal Emotional Crisis

30 Public health concerns Changes in treatment strategy to address individual, provider and systems-level barriers Improvement in perinatal mental health treatment

31 Individual level Clinical level Program level System level

32 10 Minute Break

33 Medical Model Community Mental Health Theory Social Justice Theory Life Course Theory Survivor Movement

34 Perspective: individual medical condition Appropriate Intervention: medication, psychotherapy Onset of major depressive episode must be within 4 weeks after delivery. DSM-IV

35 Perspective: Public health issue Appropriate Intervention Organizing families Activating support systems Community support groups Creating coalitions and task forces

36 Perspective: issues of inequity, oppression and social policy are determinants to health outcomes Appropriate Intervention Addressing health disparities community organizational legislative

37 Perspective: Focuses on health equity and social determinants to understand health outcomes for individuals over a lifetime and across generations Appropriate Intervention Identify critical Offer strategic interventions

38 Perspective: Mothers are critical leaders in the development of comprehensive understanding and effective interventions Appropriate Intervention Empowerment and inclusion of survivors Understanding of survivor perspective Inclusion in leadership

39 Clinical Program-level System-level

40 Initiated and led by the clinician/provider Motivational enhancement Psycho-education Psychotherapy Medication

41 Initiated and/or led at the programmatic level Staff training Universal screening Triage protocols Referral system

42 Cross system intervention and coordination Policy Development Universal protocols Organizational change

43 Medical Model Community Mental Health Theory Social Justice Theory Life Course Theory Survivor Movement Clinical Program-level System-level

44 To achieve optimal mental health outcomes for mothers and families through effective integrated care.

45 Personal Empower mothers Clinical Train and support providers System Implement effective protocols Org Change Integrate systems Policy Impact policy to support interventions

46 Engagement 1. Build the case 2. Understand the community 3. Identify key stakeholders Action 1. Assessment 2. Develop goals 3. Design and implement action plan Refinement 1. Evaluate impact 2. Evaluate process 3. Identify next steps

47 1. Build the case 2. Understand the community 3. Identify key stakeholders

48 Recruit allies Engage media for public education Review research Understand how policy impacts outcomes Utilize national best practices Provide training for professionals

49 Demographics of mothers Risk factors for PMD Geographic impact

50 1. How many births per year in your community? 2. Poverty level in your community? 3. Anticipated % of PMDs 10 20% of moms; up to 50% of moms below poverty level 4. Demographics of mothers: ethnicity, language, etc. 5. Geographic factors: rural, urban, climate 6. Protective factors

51 Stakeholders Backbone organizations Champions Leadership team

52 Crisis Services Mental Health Services Community Health Center Early Intervention Psych Inpatient DPH Hospital Perinatal Support Coalition Community Advocacy Organizations NICU Prenatal Education Family Practice Pediatric Practice Obstetrical Care Women s Shelter Obstetrics Pediatric Social Work DCF

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54 CASE STUDY: Franklin County Perinatal Support Coalition Multiple professional trainings Best practice in nursing Meetings with Key stakeholders Media coverage/ Legislative initiatives Meetings with key stakeholders

55 CASE STUDY: Franklin County Perinatal Support Coalition Population 71,372 Birth rate: 500 births per year Poverty level: 50 % Medicaid population Ethnicity & race: 91% White, 5% Hispanic Teen birth rate: 7 % Single mothers: 50% Education: 8% < 12 th grade Estimated % of PMD: 10 25% = Impact of poverty on % of PMD: 50% up to 250

56 CASE STUDY: Franklin County Perinatal Support Coalition Image, National Coalition of Mental Health Professionals and Consumers, Inc.

57 Clinical and Support Options Community Health Center Service Net Crisis Services Valley Medical Group Community Action Franklin County Perinatal Support Coalition Greenfield Pediatrics MHU Baystate Franklin Medical Center MotherWoman Pioneer Women s Health Birthplace Social Work NELCWIT

58 1. Assessment 2. Develop goals 3. Design and implement plan

59 Perform a SWOT Analysis with community Strengths Weaknesses Opportunities Threats Identify key questions for the community Medical providers trained? Status of screening? Appropriate crisis services?

60 Perform a SWOT Analysis for your community Strengths: What supports are in place for mothers? Weaknesses: What challenges are there to helping mothers in crisis? Opportunities: What next steps are apparent? Threats: What factors will make it difficult to proceed?

61 Identify 3 key questions for your community 1. Medical providers trained? 2. Status of screening? 3. Appropriate crisis services?

62 What are the goals for building a comprehensive safety net for mothers in your community? What is the gap between strengths and weaknesses? What are the top 5 priorities?

63 Training Public education Specialized support groups Resource and referral system Emergency protocols Universal screening Policy

64 Establish committees and leadership Ongoing meetings of leadership team Offer templates for actions Support initiative and innovation Create timelines

65 CASE STUDY: Franklin County Perinatal Support Coalition Hospital No screening, resources Pediatricians No screening, training, time, resources OB/Gyns and CNMs No screening, training, resources Crisis Services No triage protocols, no training Mental Health Providers Community Services Early intervention No screening, training, protected time No support group, no mentor program, no home support No screening, training, protocols

66 CASE STUDY: Franklin County Perinatal Support Coalition Establish a specialized, local support group Develop a resource and referral guide Develop and implement a comprehensive screening program Develop triage protocols Offer ongoing professional training

67 CASE STUDY: Franklin County Perinatal Support Coalition Establish roles and contributions Ongoing meetings of leadership team Communication and planning Create timelines, evaluate priorities Support initiative and innovation Address barriers

68 CASE STUDY: Franklin County Perinatal Support Coalition Barriers: Support group referrals and attendance Resistance to screening State of health care Computerized Medical Record System issues - HIPAA

69 1. Evaluate impact 2. Evaluate process 3. Define next steps

70 Individual mothers empowered Clinical providers trained Programmatic universal screening, triage protocols Organizational Change resource and referral mechanism, crisis protocols Policy organization, institution, legislation

71 Assessment Leadership team Communication Inter-agency relationships Provider engagement

72 Re-examine goals Build on successes Expand reach Identify new goals

73 CASE STUDY: Franklin County Perinatal Support Coalition Individual More mothers seek care/treatment Clinical 8 trainings, over 200 providers trained, support group Programmatic Universal screening, triage protocols, First 100 Days Plan Organizational Change Resource and referral mechanism, crisis protocols Policy Hospital and mental health policies across practices

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76 Edinburgh Postpartum Depression Scale 1. I have been able to laugh and see the funny side of things. As much as I always could Not quite so much now Definitely not so much now Not at all 1. I have blamed myself unnecessarily when things went wrong. Yes, most of the time Yes, some of the time Not very often No, never 4. I have felt scared or panicky for no very good reason. Yes, quite a lot Yes, sometimes No, not much No, not at all 7. I have been so unhappy that I have had difficulty sleeping. Yes, most of the time Yes, sometimes Not very often No, not at all 9. I have been so unhappy that I have been crying. Yes, most of the time Yes, quite often Only occasionally No, never 1. I have looked forward with enjoyment to things. As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all 4. I have been anxious or worried for no good reason. No, not at all Hardly ever Yes, sometimes Yes, very often 6. I have been feeling overwhelmed. Yes, most of the time I haven t been able to cope at all Yes, sometimes I haven t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever 8. I have felt sad or miserable. Yes, most of the time Yes, quite often Not very often No, not at all 9. The thought of harming myself has occurred to me. Yes, quite often Sometimes Hardly ever Never Source: Cox, J.L, Holden, J.M., and Sagovsky, R Detection of postnatal depression: Development of the 10- item Edinbugh Postnatal Depression Scale. British Journal of Psychiatry 150: Source: K.L. Wisner, B.L. Parry, C.M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies. Edinburgh Postnatal Depression Scale (EPDS).

77 Triage Protocols Community-Based Perinatal Support Model Protocol for use of Edinburgh Postnatal Depression Scale (Birthplace Inpatient) Score of 4 or less Score of 5-9 Score of 10 or more Positive Score on Item #10 Reveals patient is at an increased risk of Reveals patient is very likely experiencing depression, depression, anxiety or other emotional anxiety or emotional difficulties and is in need of further complication. evaluation or referral. - Educate pt and support people about - Report score to CNM the signs of depression, anxiety and - CNM will make referrals or consults as needed options and benefits of treatment (See - MD/CNM to consider psych consult (See note next Becoming a Family pgs 11-17) column) - Refer patient to a Mother-Woman - Consider social work consult if indicated support group (Greenfield, Northampton - Educate pt and support people about the signs of or Amherst) depression and anxiety, and the options for, and - Hand out and review Resource and benefits of treatment (See Becoming a Family pgs 11- Referral guide for support options 17) - Retest recommended Consult w/ - Refer patient to a Mother Woman Support Group CNM about potential need for early - Hand out and review Resource and Referral Guide postpartum visit, otherwise pt will be rescreened for support options routinely at 4 week postpartum - Instruct patient to contact Pioneer Women s Health visit) with further concerns about anxiety or depression after - Instruct patient to contact Pioneer discharge. Women s Health with further concerns - Give patient instructions of who to contact should about anxiety or depression after crisis arise after discharge. Crisis Services discharge. - Document screening tool in CIS and score on infant - Document screening tool in CIS and D/C Note score on infant D/C note - Initiate problem on problem list - Consider need to initiate problem on - Document interventions in narrative nurse s notes problem list. - Assure that written plan is in place before discharge. - Document interventions in narrative nurses notes Reveals no obvious signs of postpartum depression. Retest patient as per routine visit schedule. - Educate pt and support people about the signs of depression and anxiety (See Becoming a Family pgs 11-17) - Review availability of Mother- Woman support group (Greenfield, Northampton or Amherst) - Hand out and review Resource and Referral guide. - Document screening tool in CIS and score on infant D/C note May reveal patient is in crisis. - Report score to CNM on call - Evaluate safety of leaving patient alone or with baby (Consider initiating 1:1 care -Refer to Admin Policy #77 ID and care of the suicidal patient ) - CNM to consider Social Work consult - CNM to consider psych consult - If situation is urgent/ acute pt crisis: - Contact Social work dept ( or through switchboard after hours) - Psychiatric consultations can be placed in CIS 7 days a week. All psych consults should be entered under Peter Halperin MD. They will be seen that day if possible, but always within 24 hours. In the case of a critical emergency requiring immediate psychiatric input, an on call psychiatrist will always be available for phone consultation. Call the MHU (3-2595) and ask them to page the psychiatrist on call. - For weekend consults enter consult in CIS AND call MHU (3-2595) and ask them to notify covering psychiatrist. - Implement all other steps for pts receiving a score of 10 or more. - Document screening tool in CIS and score on infant D/C note - Document interventions in narrative nurse s notes - Assure that written plan is in place before discharge Med Ed PPD Care Pathways MedEdPPD.org

78 CASE STUDY: Franklin County Perinatal Support Coalition Pre and post comparison 90% of women screened prenatally 100% of women screened postpartum 13 % of women that screen above 10 on EPDS Increased # of referrals during pregnancy Early referrals w/ more opportunity for intervention

79 CASE STUDY: Franklin County Perinatal Support Coalition Franklin County Coalition Assessment Leadership Team Assessment Provider Screening Survey Mothers Satisfaction Survey

80 CASE STUDY: Franklin County Perinatal Support Coalition Research Fathers/partners support group Family practice providers screening & referral Professional training clinicians & prescribers Peer Support Model mother to mother Address other important perinatal issues

81 To achieve optimal mental health outcomes for mothers and families through effective integrated care.

82 Engagement 1. Build the case 2. Understand the community 3. Identify key stakeholders Action 1. Assessment 2. Develop goals 3. Design and implement action plan Refinement 1. Evaluate impact 2. Evaluate process 3. Identify next steps

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84 Franklin County Champions: Amy Olson, Sarah Carlan, Holly Christensen, Linda Jablonski and all the coalition members Linda West and the obstetrical team at Franklin Baystate Medical Center Beth Spong, Annette Cycon, and Abby Baines at MotherWoman UMass Medical School Kate Biebel, PhD Douglas Ziedonis, MD, MPH Tiffany Moore Simas, MD, MPH, MEd Jeroan Allison, MD, MS Gifty Debourdes-Jackson, MA, Rebecca Lundquist, MD Meyers Primary Care Institute Lennox Foundation Anonymous Donor, Clinical and Support Options

85 We are currently seeking partners to further develop and research this model. To learn more, contact:

86 Nancy Byatt, DO, MBA Liz Friedman, MFA Linda Jablonski, RNC, MSN MedEd PPD Edinburgh Postnatal Depression Scale Triage Protocols

87 Promoting Maternal and Infant Mental Health: The Community-Based Perinatal Support Model for Mothers AMCHP Presentation, February 2012 Nancy Byatt, DO, MBA Liz Friedman, MFA Linda Jablonski, RNC, MSN Bibliography 1. Lindahl, V., J.L. Pearson, and L. Colpe, Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health, (2): p Britton, H.L., V. Gronwaldt, and J.R. Britton, Maternal postpartum behaviors and mother-infant relationship during the first year of life. Journal of Pediatrics, (6): p Deave, T., et al., The impact of maternal depression in pregnancy on early child development. BJOG, (8): p Paulson, J.F., H.A. Keefe, and J.A. Leiferman, Early parental depression and child language development. Journal of Child Psychology and Psychiatry and Allied Disciplines, (3): p Pilowsky, D.J., et al., Children of currently depressed mothers: a STAR*D ancillary study. J Clin Psychiatry, (1): p Zuckerman, B., et al., Depressive symptoms during pregnancy: relationship to poor health behaviors. American Journal of Obstetrics and Gynecology, (5 Pt 1): p Forman, D.R., et al., Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Development and Psychopathology, (2): p Bennett, I.M., et al., "One end has nothing to do with the other:" patient attitudes regarding help seeking intention for depression in gynecologic and obstetric settings. Arch Womens Ment Health, (5): p Kopelman, R.C., et al., Barriers to care for antenatal depression. Psychiatric Services, (4): p Flynn, H.A., et al., Patient perspectives on improving the depression referral processes in obstetrics settings: a qualitative study. General Hospital Psychiatry, (1): p Kim, J.J., et al., Barriers to mental health treatment among obstetric patients at risk for depression. American Journal of Obstetrics and Gynecology, (3): p. 312 e Dennis, C.L. and L. Chung-Lee, Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth, (4): p Sword, W., et al., Women's care-seeking experiences after referral for postpartum depression. Qualitative Health Research, (9): p

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90 48. Kobokovich, L.J., Use of accelerating clinical improvement in reorganization of care: the Dartmouth-Hitchcock Medical Center experience. J Obstet Gynecol Neonatal Nurs, (3): p Miller, J.H. and T. Moyers, Motivational interviewing in substance abuse: applications for occupational medicine. Occup Med, (1): p , iv. 50. Ingoldsby, E.M., Review of Interventions to Improve Family Engagement and Retention in Parent and Child Mental Health Programs. J Child Fam Stud, (5): p Smith, M.V., et al., Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics. Psychiatric Services, (4): p LaRocco-Cockburn, A., et al., Depression screening attitudes and practices among obstetriciangynecologists. Obstet Gynecol, (5 Pt 1): p Byatt N BK, Lundquist R, Moore Simas T, Debourdes-Jackson G, Allison J, Ziedonis D. Overcoming the Barriers to Perinatal Mental Health Treatment: Perspective of Ob/Gyn Providers In; 2012 (submitted). 54. Byatt N BK, Debourdes-Jackson G, Lundquist R, Moore Simas T, Ziedonis D, Allison J. Overcoming the Barriers to Perinatal Mental Health Treatment: Perspective of Postpartum Women In; 2012 (in preparation). 55. Matthews, Connie R. & Adams, Eve M. Using a Social Justice Approach to Prevent the Mental Health Consequences of Heterosexism. (2008). Springer Science and Business Media. Published online. 56. Elder, G. H. (1998). "The Life course as developmental theory." Child Development, 69: Rethinking MCH: The Life Course Model as an Organizing Framework. Concept Paper. U.S. Department of Health and Human Services Health Resources and Services Administration Maternal and Child Health Bureau. November, 2010 Version Morrison, Linda J. Talking Back to Psychiatry: The Psychiatric Consumer/Survivor/Ex-Patient Movement (New Approaches in Sociology). (ISBN 10: / ISBN 13: )