A NEIGHBORHOOD NETWORK OF CARE FOR PREGNANT WOMEN AND...

transcript

W O M E N ’ S H E A L T H P R O G R A M S & I N N O V A T I O NL O S A N G E L E S C O U N T Y D E P A R T M E N T O F H E A L T H

S E R V I C E S2 / 1 2 / 1 9

A NEIGHBORHOOD NETWORK OF CARE FOR PREGNANT WOMEN AND FAMILIES

Introductions

Dr. Erin Saleeby, MD, MPH

Director of Women’s Health Programs & Innovation

Moraya Moini, MPH

Program Director, Strong Start Initiative – MAMA’s Neighborhood

Dannelle Pietersz, NP, MSN, MPH

Family Planning Clinical Programs Manager

Dr. Ashaki M. Jackson, MFA, Ph.D

Research and Evaluation Portfolio Manager

Brandi E. Sankey, MPH, MS, MCHES®

Health Educator, Baby Boutique Program Manager

Strong Start - MAMA’s Neighborhood

M – Maternity April 2013 - Los Angeles County Department of

A – Assessment Health Services (LACDHS) Division of Women’s

M – Management Health Programs & Innovation established a

A - Access and new, strategic platform of comprehensive,

S – Service synergy coordinated and continuous care for women and

throughout the their families.

Neighborhood – for CMS funded program focus is to improve

Health pregnancy and birth outcomes by addressing

social determinants that impact rate of preterm birth

and low birthweight.

Women’s Health Programs & Innovation

Comprehensive Women’s Health Services at DHS include:

Well-Woman Care

Prenatal Care

Family Planning

Specialized Obstetrics & Gynecology Services

Primary Prevention

Services are provided to women of all ages and stages in life.

Model & Care Domains

CARE DOMAINS

1. Substance Use

2. Social Support

3. Mental Health

4. Biomedical

Maternal-Centered Medical Home

Patient registers with DHS as their maternity home.

Initial clinical and social care assessment to identify strengths and areas of improvement.

Multi-disciplinary team of clinical and social care professionals coordinate care, and connect/link patients with Neighborhood Network pathways of care.

Uses evidence-based measures and quality indicators to aid in continuous quality improvement activities.

Utilize electronic health records and empanel mothers to support continuity of care, and identify strengths and gaps in care.

Offer proactive clinical and social care teams that honor perinatal period as critical a window for intervention and improvement, and special time for mothers.

Team Services

Care Coordinators

Maternity mental health providers

Social workers

Health Educators

Doctors

Nurses

Nutritionists

Community based organizations and agencies

Prenatal Education and Resiliency Classes (Fathers included)

Housing assistance

WIC and other food services

Substance use treatment

Childhood education resources

Hospital tours

Pediatrics and well women care

“Mobile MAMA”

Family Planning

MAMA’S Visits (Home Visits)

MAMA’s Neighborhood Team and Services

Who is Eligible?

Enrolled as a prenatal patient with Los Angeles County Department of Health Services (LAC-DHS).

Patients receive services through their pregnancy period, and up to 10 weeks postpartum.

When the timeframe for medical services with MAMA’S ends, we connect patients to a DHS women’s health provider and pediatrician to continue medical care.

Patients’ Age Groups

O V E R H A L F P A T I E N T S E N R O L L E D ( 2 9 . 2 % + 2 6 % ) W E R E B E T W E E N T H E A G E S O F 2 0 T H R O U G H 2 9 Y E A R S O L D

Patients’ Race

M O S T P A T I E N T S D I D N O T D I S C L O S E T H E I R R A C E

A B O U T O N E - F I F T H O F T H E P A T I E N T S ( 2 1 % ) I D E N T I F I E D A S W H I T E

E X A C T L Y A F I F T H ( 2 0 % ) I D E N T I F I E D A S B L A C K

Patients’ Ethnicity

C L O S E T O T W O T H I R D S ( 6 3 % ) D E S C R I B E D T H E I R E T H N I C I T Y A S H I S P A N I C / L A T I N O

Patients’ Gestational Age at Intake

A B O U T T W O T H I R D S ( 6 5 % ) O F P A T I E N T S E N R O L L E D W E R E I N T A K E D U R I N G T H E I R F I R S T T R I M E S T E R

Clinical Risk Factors

Having an unintended pregnancy (57%), having their first pregnancy (31%), and maternal age greater than 35 yrs. (18%) are the highest risk factors

Referrals to Assessed Service Needs

Progres To Date

Upgrading service sites for improved patient experience

Comprehensive intake assessment

Electronic health record

Individualized Care Plans

Warm in-house hand-offs

Continuity of coordinated care

Breastfeeding support Referral directory Mobile MAMA Prenatal Classes revamped for education and resiliency skills Baby Boutique MAMA’S Visits – Whole Person Care

Baby Boutique

Program Overview

Baby Boutique is a program developed by the Women’s Health Programs & Innovation with Los Angeles County Department of Health Services to help improve pregnancy and birth outcome across Los Angeles County.

Designed to help families obtain items needed for growing families to give children healthier start in life.

New and lightly used baby items are donated from outside agencies for the purpose of redistribution to patients. (Baby 2 Baby & Good + Foundation).

Items are redistributed to patients at various times throughout their pregnancy period. (Intake through postpartum).

Participants receive services through: Clinic/Hospitals, MAMA’S Visits, and Fast Track/Prenatal Classes.

Our Neighborhood

Hospitals and Clinics

Harbor-UCLA Medical Center

21840 S. Normandie Ave.

Torrance, CA 90502

LAC+USC Medical Center

1100 N. State St.

Los Angeles, CA 90033

Olive View-UCLA Medical Center

14445 Olive View Dr.

Sylmar, CA 91342

Bellflower Health Center

10005 E. Flower St.

Bellflower, CA 90706

El Monte Comprehensive Health Center

10953 Ramona Blvd.

El Monte, CA 91731

Martin Luther King Outpatient

1670 E. 120th St.

Hubert Humphrey CHC

5850 S. Main St.

Wilmington Health Center

1325 Broad Ave.

Wilmington, CA 90744

Long Beach Comprehensive Health Center

1333 Chestnut Ave.

Long Beach, CA90813

MAMA’s Neighborhood Locations

Psychosocial Risk Factors

M O R E T H A N H A L F ( 5 6 % ) A R E U N D E R - O R U N E M P L O Y E D A N D A R E I N N E E D O FS A F E T Y N E T T Y P E S E R V I C E S ( I . E . , I M M I G R A T I O N , E T C . 5 4 % )

A T L E A S T A T H I R D O F T H E P A T I E N T S H A V E N E E D S I N A R E A S O F E M P L O Y M E N T , E D U C A T I O N , A N D A R E U N M A R R I E D W I T H O R W I T H O U T A P A R T N E R

A T L E A S T A Q U A R T E R H A V E N E E D S I N A R E A S R E L A T E D T O H O U S I N G , T R A N S P O R T A T I O N A N D V I O L E N C E I S S U E S

A L M O S T A F I F T H O F T H E M H A V E E M E R G E N C Y F O O D ( 1 9 % ) A N D A L A N G U A G E B A R R I E R I S S U E ( 1 8 % )

Pregnancy Outcomes

M O S T ( 8 5 % ) O F P A T I E N T S ’ B I R T H S A R E A T T E R M

O N L Y 5 % P R E T E R M A N D V E R Y P R E T E R M

Pregnancy Outcomes

T H E M A J O R I T Y ( 8 6 % ) O F N E W B O R N ’ S W E I G H T I S W I T H I N T H E N O R M A L R A N G E

Referral Process

To refer a patient - Please visit our secure website using the following link: tinyurl.com/mamas4u

For program questions, (e.g. partnership, outreach, education, more information, etc.) e-mail us at mamas@dhs.lacounty.gov

For more information, call 844-37-MAMAS.

Whole Person Care – Los Angeles

Whole Person Care – Los Angeles (WPC-LA) delivers seamless, coordinated services to LA County’s most vulnerable Medi-Cal beneficiaries.

High risk

High hospital and emergency department utilization

WPC-LA brings together health and social service agencies to build integrated systems that help provide resources and support.

Homelessness

Justice involvement

Serious mental illness

Substance use disorders

Complex health conditions

Barriers to health pregnancy

The Big Picture

http://dhs.lacounty.gov/wps/portal/dhs/wpc

MAMA’S Visits

Provides support to pregnant and patenting mothers.

Includes mothers who are currently incarcerated, recently released.

Century Regional Detention Center (CRDF)

Office of Diversion & Reentry (ODR)

Extension of MAMA’S Neighborhood.

Mobile Care Team (MCT) provides coordinated and compassionate home-or community based care management services.

Care management is personalized to support low income pregnant and patenting mothers with complex, stressful life issues.

Up to 18 months of quality medical care. (Beings at time of enrollment)

Provides visitation services and support until child is 1 year of age. (Can extend services based on needs).

Focus on preterm birth reduction.

Team Services

Care Coordinators

Maternity mental health providers

Clinical/Psychiatric Social workers

Health Educators

Doctors

Clinic/Public Health Nurses

Community based organizations and agencies

Home or community-based care and support visits (MCTs)

Prenatal care linkage with doctor at MAMA’S Clinic. Birth planning at a MAMA’S Hospital

Family planning education and support

Linked connection to advanced health services: psychiatry, substance use support, violence counseling, high-risk doctors

MAMA’S Visits Team and Services

Services

Group Educational Classes

Pregnancy

Stress reduction

Breastfeeding

Parenting and baby bonding/development

Family planning education

Community Referrals

WIC, housing, jobs, training

School enrollment, childcare

Legal support, transportation

MAMA’S Visits Services Continued

Educational guidance

Healthy pregnancies

Recovery after birth

Baby attachment and development

Mother’s meet-up socials to celebrate motherhood and build a family

Family planning education

Partners for a Healthy Baby

Florida State University – Center for Prevention & Early Intervention Policy.

Research and evidence based home visiting curricula series.

Book series includes:

Before Baby Arrives

Baby’s 1st Year

Baby’s 2nd Year

Toddler’s 3rd Year

Use curriculum to fidelity across all Service Planning Areas (1-8).

Who is Eligible?

Pregnant or recently delivered (enrollment up to 3 months postpartum).

Medi-Cal eligible or low-income.

LA County resident.

Experiencing complex stressful life circumstances.

Identified as medically complex through interview process.

Experience the following indicators:

Preterm birth

Preterm birth risk

History of miscarriage

High blood pressure

Drug use

Level 2 or 3 global risk score (Perinatal Service Intake)

African American

Referral Process

To refer a patient - Please visit our secure website using the following link: tinyurl.com/mamas4u

For program questions, (e.g. partnership, outreach, education, more information, etc.) e-mail us at mamas@dhs.lacounty.gov

For more information, call 844-37-MAMAS.

Hospitals and Clinics

21840 S. Normandie Ave.

Torrance, CA 90502

LAC+USC Medical Center

1100 N. State St.

Olive View-UCLA Medical Center

14445 Olive View Dr.

Sylmar, CA 91342

Bellflower Health Center

10005 E. Flower St.

Bellflower, CA 90706

El Monte Comprehensive Health Center

10953 Ramona Blvd.

El Monte, CA 91731

Martin Luther King Outpatient

1670 E. 120th St.

Hubert Humphrey CHC

5850 S. Main St.

Wilmington Health Center

1325 Broad Ave.

Wilmington, CA 90744

Long Beach Comprehensive Health Center

1333 Chestnut Ave.

Long Beach, CA90813

Los Angeles County Service Planning Areas (1 – 8)

MAMA’s Neighborhood Locations

Regional Team Member (SPA’S 1&2)

Karla Brito, MPH, CHES®

Health Educator

Olive View – UCLA Medical Center

(747) 210-4407

kbritogonzalez@dhs.lacounty.gov

Antelope Valley Partners for Health with Children’s Bureau and Black Infant Health

Northridge Hospital Medical Center

Providence Holy Cross Medical Center

Valley Presbyterian Medical Center with El Nido Family Centers

All Health Educators share regional services in SPA 5

Brandi E. Sankey, MPH, MS, MCHES®

Health Educator

LAC-USC Medical Center

(323) 914-8338

bsankey@dhs.lacounty.gov

California Hospital Medical Center with Maternal Child Health Access

Citrus Valley Medical Center – Queen of the Valley Campus

White Memorial Medical Center

Eunice N. Soriano, MPH

Health Educator

Hubert Humphrey Comprehensive Health Center

Martin Luther King, Jr. Outpatient Center

(323) 914-8334

esoriano@dhs.lacounty.gov

Martin Luther King Hospital with SHIELDS for Families

St. Francis Medical Center with SHIELDS for Families

Angelica Campos, MPH, MSW

Health Educator

(424) 306-7220

acampos3@dhs.lacounty.gov

Centinela Hospital with SHIELDS for Families

Long Beach Memorial-Miller Children’s and Women’s Hospital

Providence Little Company of Mary – San Pedro

St. Mary Medical Center with Families in Good Health

Torrance Memorial Medical Center

THANK YOU FOR LISTENING

Brandi E. Sankey, MPH, MS, MCHES®Health Educator

(323) 914-8338bsankey@dhs.lacounty.gov

If you have questions about partnerships, please contact:

Angelica Campos, MPH, MSWHealth Educator

(424) 306-7220acampos3@dhs.lacounty.gov

A NEIGHBORHOOD NETWORK OF CARE FOR PREGNANT WOMEN AND...

Documents