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Supporting a high value maternity system of care: prioritizing resilience of and relationships with mothers to improve maternal and child health
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Supporting a high value maternity system of care: prioritizing resilience of and relationships with mothers to improve maternal and child health
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SUPPORTING A HIGH VALUE MATERNITY SYSTEM OF CARE: PRIORITIZING RESILIENCE OF AND RELATIONSHIPS WITH MOTHERS TO IMPROVE MATERNAL AND CHILD HEALTH by Moraya A. Moini, MPH A Dissertation Presented to the FACULTY OF THE USC SOL PRICE SCHOOL OF PUBLIC POLICY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF POLICY, PLANNING AND DEVELOPMENT August 2020 Copyright 2020 Moraya A. Moini ii Dedication I dedicate this dissertation to my two beautiful children, Giovanni (3.5 years) and Natalia (1 year), who were given to me by miraculous moments, with whom I share my deepest love, who inspire me to persevere, and for whom I want to show that motherhood is a gift. My bond with you is unbreakable. Thank you for giving me the chance to actualize my most innate dreams of becoming a mother so that I may witness my heart grow in ways unimaginable, and nurture you both to actualize your own dreams. I show you here that knowledge is power and can never be taken from you, and anything is possible when heart and mind adjoin. iii Acknowledgements There are many people in my life that have influenced my career choices and life decisions, too many to name. To briefly cover an important few, I appreciate them here in this document’s acknowledgements. In my life, there has been no stronger cheerleader than my father, Reza Moini, MA, PE, for higher education and all that comes with achieving those degrees. He gave me the examples of perseverance, loyalty, fearless inquiry, and deductive logic to model as I developed my yearning for knowledge. At every turn or valley in my life, my father celebrated and comforted me, and for that I am eternally grateful. Without him, this degree would not have come to fruition. As well, my mother never ceased to encourage me to understand and fight for women’s equality all around, be structured and disciplined in life, and go the extra mile because most barriers in life were mind over matter. My sister has always been by my side, rooting me on. With these skills, I was able to overcome the many concurrent pauses endured during this degree, including realizing my dreams of creating a family, experiencing pregnancy, having two glorious children (Giovanni, 3 years, Natalia, 1 year), building a Countywide Perinatal Health Program from ground up, changing those accompanying antiquated policies and practices, and writing three federally funded grants to augment these services. It is ironic that in my fight for better pregnancies and birth outcomes that both my pregnancies became high-risk; luckily, I had trusted physicians who trusted me, was a Doula myself, and had a support system to lean on when times were rough. Last, I would like to thank my intelligent, loving and dynamic husband, Noel Vasquez, who sacrificed willingly much of himself to support me through the end of this journey. He sees a light in me that burns brightly, supports me in my goals and gave me the best parts of my life – my children. iv Second, without the tireless support of my Chair, LaVonna Lewis, PhD, and Dissertation Advisors, Deborah Natoli, PhD, Karina Celaya, MD, MPH and Emily Scibetta, MD, at the University of Southern California, Sol Price School of Public Policy and LA County Department of Health Services Women’s Health Programs and Innovation, respectively, this project would not be possible. It has been a long-term goal of mine to achieve this advanced degree, and what made this unique was the requirement for not just inquiry, but for a “contribution to practice.” The degree also emphasized the sound investment in authentic collaboration as a means for successful leadership cultivation in public entities, decision making among community partnered efforts, and sustainable change. The School and my Chair did not shy away from my fierce beliefs and experience in these areas, and further encouraged me to explore my deep commitment to maternal reproductive justice and reducing health disparities that elevates their voices, autonomy, equity and rights of mothers during their perinatal periods over their lifecourse so as to live a better quality of life; and in turn, heal any wounds and activate strengths to give their babies a healthy, strong and loving start in life. Thank you, Drs. Lewis and Natoli, for believing in my capabilities, and admitting me into this exceptional program, and allowing me to get my second higher education degree here at USC. Thank you Drs. Celaya and Scibetta for being there for the many seminal events in my life. I would also like to thank my mentors and colleagues over the last 20 years of my career who I learned from day to day and with whom I made advances in understanding and publishing on community engagement and health disparities when it was not comfortable to do so in the realm of health. They include: Emily Dossett, MD (LAC-DMH), Emily Scibetta, MD (LACDHS, Ventura County DHS), Janice French, CNM (LA Best Babies Network), Loretta Jones, MA, DD (passed) and Felica Jones (Healthy African American Families), Kenneth Wells, MD, MPH v (UCLA Center for Health Services and Society), Paul Kogel, PhD (RAND), Keith Norris, MD PhD, (UCLA), James McGregor, MD (retired USC OB/GYN and researcher), Carolina Reyes, MD (CHCF Board Member; Racial and Ethnic Disparities in Health IOM Advisor; Researcher, USC; LA Best Babies Network, former), Lynn Yonekura, MD (LA Best Babies Network), and Michael Lu, MD, MPH (Dean, UC Berkeley School of Public Health, UCLA David Geffen School of Medicine and Center for Children, Families and Communities). Last, but not least, I thank Erin Saleeby, MD, MPH for her stewardship to advance women’s health progressively and proactively within Los Angeles County, her belief in my ability to assist her in making change a reality at DHS for mothers, and for her unabashed way of asking, “why not.” And, I thank the team at LACDHS WHPI for their significant contributions to MAMA’S Neighborhood; namely, the original Care Coordinators who banded together to build this program from scratch with me and Dr. Saleeby. Readers may learn more about LACDHS’ Women’s Health Programs & Innovation and our newly expanded and enhanced clinic and home visitation program, MAMA’S Neighborhood, at this link: http://dhs.lacounty.gov/wps/portal/dhs/wh/pregnancy/mamas/ vi Table of Contents Dedication ii Acknowledgements iii List of Tables ix List of Figures x Abstract xi Chapter 1 Introduction 1.1 National Birth Outcomes Statistics 16 1.2 Birth Outcomes and Mortality for California and Los Angeles County 18 1.3 LA County Regional Health Behaviors and Social Determinants of Health (SDOH) 19 1.4 Birth Outcomes and Mortality by LA County Service Planning Area (SPA) 23 1.5 Summary 25 Chapter 2 Literature Review 2.1 Background 28 2.2 Overview 30 2.3 Race, Racism and Health Disparities 31 2.4 Perinatal Phases and Their Significance 35 2.4.1 Why Does Pregnancy Matter? 35 2.4.1.1 Doulas (Lay Health Advisors) and Maternal Infant Health 43 2.4.1.2 Social Conditions and Stressors 45 2.4.1.3 Social Stressors and Development of Depression/Anxiety 46 2.4.1.4 Doulas and Stress and Attachment 46 2.4.1.5 Stress and Biology 48 2.4.2 Why Does Birth Matter? 51 2.4.2.1 Overview/History 51 2.4.2.2 Doulas and Biological Outcomes 52 2.4.2.3 Financial Costs of Birth 54 2.4.2.4 The Psychology of Birth 55 2.4.3 Why Do the Postpartum and Interconception Periods Matter? 59 2.4.3.1 The Significance of Maternal Infant Health Phases 64 2.4.3.2 Models and Strategies to Improve Maternal Infant Outcomes 64 2.4.3.3 Summary 70 2.5 Importance of Program Evaluation 71 2.6 Frameworks for Organizational and Individual Change 72 2.6.1 Organizational Planning Theory and Framework 72 vii 2.6.1.1 Brief History 72 2.6.1.2 Cultural Competency in Planning 76 2.6.1.3 Organizational Readiness to Change and Resilience 78 2.6.2 Individual Change Theories/Models 88 2.6.2.1 Maslow’s Hierarchy of Needs 88 2.6.2.2 Transtheoretical Model of Behavior Change 91 2.6.2.3 Closing/Summary 92 Chapter 3 Methodology 3.1 Transformation of Prenatal Care at DHS: MAMA’S Neighborhood and Readiness for Change 93 3.2 Policy Question 93 3.3 Study Aims 93 3.4 Study Conceptual Models 94 3.5 Overarching Participatory Models of Individual and Organizational Change 99 3.5.1 Collaborative Governance/Appreciative Inquiry 99 3.5.2 Theory Used to Make Organizational Change 100 3.5.3 Diffusion of Innovation/Care Transformation 102 3.6 Data Collection 3.6.1 Overview 105 3.6.2 Prework: Internal Preparation for Change 105 3.6.2.1 Perinatal Data, Landscape Analysis 105 3.6.2.2 Step 1: Lay the Foundation for Organizational Change 106 3.6.2.3 Step 2: Organizational Reflections 108 3.6.2.4 Step 3: Organizational Grounding 109 3.6.2.5 Step 4: Organizational Action 110 3.6.2.6 Step 5: Organizational Change Sustainability 111 3.6.3 Summary 112 Chapter 4 Program Adoption, Implementation Tools and Results 4.1 Overview 113 4.2 Paradigm Shifts 114 4.3 Critical Pathways 114 4.4 Phase I: Lay the Foundational for Organizational Change 115 4.4.1 Making the Case for Clinics 115 4.4.2 Organizational Readiness 115 4.4.3 SWOT Analysis 119 4.4.4 Collaborative Partnership 125 4.4.5 Driver Diagram 127 4.4.6 Core Principles and Levels of Mother Engagement in Care 129 4.4.7 Summary 133 4.5 Phase II: Building the House for Organizational Change 133 4.5.1 Defining the Service Delivery Package 133 4.5.2 Components of Clinical Transformation Identified 136 4.5.3 New Clinical Care Workflow 140 4.5.4 Description of Enhanced Care Components 142 viii 4.6 Phase III: Maintaining the Infrastructure for Organizational Change 155 4.7 Chapter 4 Summary 160 Chapter 5 Recommendation and Conclusion 5.1 Study Discussion 163 5.2 Paradigm Shifts 165 5.3 Critical Pathways 166 5.4 Recommendations 170 5.4.1 Recommendation 1 170 5.4.2 Recommendation 2 172 5.4.3 Recommendation 3 173 5.4.4 Recommendation 4 178 5.4.5 Recommendation 5 178 5.5 Opportunities for Future Research and Activities 179 5.6 Conclusion 180 Bibliography 182 Appendix Contribution to Practice 199 MAMA’S Neighborhood Implementation Manual (excerpted) ix List of Tables Table 4.1 Organizational Readiness Assessment 117 Table 4.2 SWOT Analysis 122 Table 4.3 Tenets of the Different Levels of Mother Centered Care 131 Table 4.4 Mother Centered Service Package 133 Table 4.5 New Components of Care Transformation Identified 137 Table 4.6 Patient Feedback for PNER Class Structure 148 Table 4.7 Current Structure of PNER Classes 149 Table 4.8 Staffing Model 151 Table 4.9 AHRQ EvidenceNOW Key Drivers for Organizational Change Components 156 x List of Figures Figure 2.1 Organizational Resilience (Duchek, 2019) 82 Figure 2.2 Building Organizational Strength 85 Figure 2.3 Maslow’s Hierarchy of Needs 89 Figure 2.4 The Stages of Change (simple) 91 Figure 3.1 Mother-Centered Care Model (Moini & Saleeby, 2017; Moini, 2012) 95 Figure 3.2 The Care Model for Perinatal Health (LABBN, 2003) 98 Figure 3.3 Transtheoretical Model – Stages of Change (Prochaska and DiClemente, 1983; Prochaska, DiClemente and Norcoss, 1992) 101 Figure 3.4 Institute for Healthcare Improvement – Model for Improvement 103 Figure 4.1 Multisystem Construct of MAMA’S Neighborhood: How We Work 126 Figure 4.2 MAMA’S Neighborhood: Driver Diagram 128 Figure 4.3 Pre-Care Transformation Workflow 140 Figure 4.4 New Care Transformation Workflow 141 Figure 5.1 DHS Women’s Health Services Change Wheel 164 xi Abstract Poor birth outcomes, as defined by preterm birth and low birthweight, continue to plague mothers who face more psychosocial adversities. Not only do public health systems financially suffer, but families suffer, too, as they try to mitigate a higher risk of infant mortality, as a result, and longer recovery periods once discharged home, which can be several months after birth. These unrelenting negative experiences can take a toll on a mother, also, putting her at higher risk for postpartum depression and deeper feelings of guilt. Babies born too early (prior to 37 weeks) can experience lifelong struggles with social, cognitive, and physical developmental delays, including learning disabilities and chronic health problems. When born too early, the cost of a premature baby can rise to twenty-five time higher than a baby born full term (March of Dimes, accessed 2020). Unfortunately, if you are African American and/or Black race as a mother, the chances for these adversities are much higher than the average rate for all race/ethnicities, and daily life attention to mitigate possible predicators and contributors is critical. The rate of preterm birth in Los Angeles County and California is 8.9% and 12% respectively, with the highest rate in African American and Blacks (11.7%) (LADPH 1 , Perinatal Health Indicators & LAMBS 2 Reports 2016). Highest all race/ethnicity representations are seen in Service Planning Areas 1 (8.7%), 4 (9.4%), 6 (8.8%) and 8 (9.2%) (LADPH, LAMBS 2016) 3 . As well, in Los Angeles County, low birthweight rates were 7.1% overall and 11.7% for African Americans and Black infants. Mortality for infants and mothers is also of concern and major interest to public health and community advocates, as these rates are largely associated with pre- pregnancy, prenatal and delivery conditions, many sometimes unmanaged in lower socioeconomic 1 LADPH: Los Angeles Department of Public Health 2 LAMBS: Los Angeles Mothers and Babies Survey 3 Los Angeles County is divided into eight service planning areas: 1-Antelope Valley, 2-San Fernando Valley, 3-San Gabriel Valley, 4-Metro, 5-West, 6-South, 7-East, 8-South Bay. xii groups. Mothers and infants suffer mortalities more by race, specifically and again, in African American and Blacks. Continuing to rise, rates of maternal mortality reported a ten-year average between 2007-2016 for African American and Blacks living in Los Angeles County at 65.8 per 100,000, a rate more than five times that of Whites (12.4 per 100,000). Infant mortality rates for Los Angeles County numbered 4.0 deaths per 1000 live births (years 2007-2016), with African American and Black babies dying at more than two-times the overall rate at 10.4 per 1000 live births (LADPH, 2018). These rates exemplify the dire need for monetary investment to tailor, race-specific, creative interventions to African American and Black mothers, but, more so, the absolute need for the Los Angeles County health system to honestly reflect on what can be done systemically to meet mothers where they begin and improve accountability, performance, transparency and quality of the preventive and direct health services provided. Instead of expecting trust from mothers because of the ego inherent in medicine, health systems can self- reflect and change their organizational values to be trustworthy. In the last twenty years, research literature has named birth outcomes disparities and published these findings; however, popular climate to digest and ignite change was not existent. More recently, popular press has “gotten wind” of these viciously high rates among African America and Black women, probably due to popular icons having near death experiences or dying. Literature, as well, has started to change its tone and use more brave terminology such as “racism” as a social determinant of health, and broach the difficult topic and negative impacts of structural racism on birth outcomes. The challenge in current clinical organizational and systemic climates has been to find the balance between less personal, new technologies and the “heart and hands” of healing toxically stressed-out, marginalized mothers under the demands of insurance and national economic policies. xiii Although programs to address improvement of birth outcomes exist, such as California’s, Black Infant Health and Comprehensive Perinatal Services Program (CPSP), various home visiting programs, Centering Pregnancy, and Nurse Family Partnership, poor rates remain. Community based models like Mamatoto Village (New York), Northern Manhattan Perinatal Program (New York), JJ Way (Florida), and various independently owned midwifery and Doula practices have filled the cultural gap of perinatal health with these more mother centered health and support models. Typically, they do not admit medically high-risk mothers under their care, which has been their scrutiny; however, what, how and when they work with mothers is something of which to take notice. In health care currently, there is not a reimbursement mechanism for care coordination and support, except CPSP however, it is embarrassingly low, and so, many providers do not perform them under an evidence based lens and just collect the small added dollars. To test different mother centered models and gather evidence for a more robust reimbursement model, the Center for Medicare and Medicaid Services (CMS), under their Innovations (CMMI) branch, set out to test three different models of perinatal care with the aim of improved birth outcomes in 2012-2013. These included Maternity Centered Medical Homes (MCMH), Centering Pregnancy™ (group prenatal care) and Birth Centers care. Through a competitive process, LACDHS received this funding and chose to implement the MCMH model, locally branded as, “MAMA’S Neighborhood” as the government-based system was already a Patient Centered Medical Home model for primary care; value for tailored care had been laid. An acronym for Maternity Assessment Management Access and Synergy throughout the Neighborhood, MAMA’S uses the possessive form (‘S) to further emphasize that the program is owned by the mother. This shift in value is critical first step that was made to reorganize executive and frontline’s opinion of patients. Although a monumental overhaul of its current perinatal health care delivery structure, xiv the new Women’s Health Director made the initial commitment needed to begin the paradigm shift to include a more comprehensive, neighborhood-based, coordinated model that meaningfully would prioritize an activated system of providers prepared to deliver care that was collaborative, engaging and embracing to mothers in ways that would support the healthiest pregnancy and birth. This tectonic shift, however, required major organizational change to occur still at its design level and its local perinatal clinical centers, detailed implementation plans, and continued executive level values-based assessments. Therefore, to address this complex organizational change and position itself as a provider of choice, a feasibility analysis was performed to examine the paradigm shifts and critical pathways necessary to implement a mother centered care model at DHS Women’s Health Services. The aims of this study were three-fold: 1) to frame and agree upon the remodel conceptually, 2) to assess the organizational readiness to change, and 3) to define the enhanced clinical components of care that would remodel and maintain the care to be mother centered. To achieve these aims, this research first espoused a collaborative and appreciative inquiry framework to approach, implement and achieve organizational change. Methods to conduct this analysis were to administer an organizational readiness assessment to five selected DHS perinatal clinics, conduct a SWOT analysis, and clearly delineate the gaps in traditional perinatal care service delivery by conducting clinical observations and collegial planning meetings with executives and the Women’s Health Director. Last in this organizational change arc was the attention to planning the infrastructure to sustain and maintain this organizational change. The Agency for Healthcare Research and Quality (AHRQ) EvidenceNOW Organizational Change Driver Diagram was utilized to compare and contrast to the Phase I MAMA’S Neighborhood model what was feasible to put in place now versus labelled as a future aim (or current gap). xv As a result of this inquiry, analyses were used to inform the development of MAMA’S Neighborhood framework and implementation manual which is this study’s contribution to practice. Paradigm shifts and three critical pathways emerged. Although compliance with Managed Care Organizations and CPSP was an impetus for institutional change, the egregious rates of poor birth outcomes seen within the DHS women’s population and interest in value adds were heavily weighted reasons that pushed DHS Executive Leadership to approve steps toward this massive change. Resultant from this contribution to practice were changes in countywide institutional policies to serve pregnant and parenting mothers, delineation of shifted program level philosophies and guiding tenets on how to frame care, clinical service delivery enhancements, and an organizational change maintenance infrastructure rooted in quality improvement methodologies. Described in this report are the paradigm shifts and critical pathways needed to move a traditional, hierarchal complex bureaucracy of government health care to be more community based, participatory on every level, and mother centered. Recommendations are delineated for potential next steps as the program continues to evolve, as well as, opportunities for future research. Keywords: MCH, high value maternity, collaborative care, PTB, adverse birth outcomes, perinatal care, postpartum, interconception, maternity centered medical home, MCMH, organizational readiness, organizational resilience, maternal mortality, infant mortality, LACDHS, relationship-based care, care coordinator, community health worker, model for improvement, readiness-based care management, mother-centered care 16 Chapter 1 Introduction National Birth Outcomes Statistics Nearly four million babies are born each year in the United States (CDC, National Center for Health Statistics, 2018). Every mother and every baby deserve the embrace needed to be healthy and acknowledged as a worthy investment of time and resources. However, antiquated systems focused on processes rather than people have dominated institutions meant for ‘health’, leaving mothers to defend their rights to be served equally and not by favor, and their babies to be caught in between. One such area affected by this systemic imbalance is during pregnancy, birth and postpartum care. Preterm birth (< 37 weeks gestation) and low birthweight (< 2500 grams) and very low birthweight are the leading causes of infant morbidities and mortality in the US. They number nearly 500,000 (or 1 in every 8 infants) per year and cost the health system $26 billion annually (March of Dimes, 2020; IOM, 2007; Behrman, et al, 2006). Preterm birth rose to 10.02% in 2018 from 9.93% in 2017, with the African Americans and Blacks’ rate reaching 14.13% while the rates were 9.73% and 9.09% for Hispanic and white women, respectively (Martin JA et al., 2019). Likewise, the overall rate was 8.28%, and disparities still exist at 13.3% for non-Hispanic Black infants as compared to non-Hispanic whites at 6.9%. Not only does infant mortality increase, but infants born too early or underweight have an increased risk of childhood morbidities like cerebral palsy, slowed cognitive function, heart defects, to name a few (McCormick MC, et al, 2011; Behrman, et al , 2006), and often need a lifetime of medical, developmental and cognitive interventions, which often impact their adult life’s productivity and quality of life. It is also well documented empirically that infant mortality is disparately experienced by African Americans and 17 Blacks at the rate of two times their white counterparts (Martin, JA, et al, 2019; Lu and Halfon, 2005; Behrman, et al, 2006; Collins, J. et al, 2004). Among infants of non-Hispanic Black women, 44.2% infant deaths were related to preterm birth and its complications (or 11.1 deaths per 1000 live births), as compared to an overall rate of 6 infant deaths per 1000 live births nationally and 5.2 per 1000 for non-Hispanic white women. (March of Dimes, accessed 2020). Reducing these objectionable rates would have great impact on a population and family’s health over generations, making this a public health priority and emergency. Significant racial disparities also exist in maternal mortality at three to four times the rate between Black mothers and all other mothers (CMQCC, 2020; CDC, 2020; Culhane JF, et al 2011). Maternal mortality (or pregnancy-related death) is defined, “as the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication,” (CDC, 2020). The Center for Disease Control and Prevention (CDC) estimates that maternal mortality has seen a sharp increase over the past 25 years of 50% (700 women annually), with 60% of those being preventable (CDC, accessed 2020), and in California alone, the rate doubled between 1999 and 2006. A third of these deaths were cardiovascular in nature (heart attack and stroke), with hemorrhage close behind. Non-Hispanic Blacks experience three- or four-times higher rate of maternal mortality than Whites (Creanga, et al, 2015; Callaghan, 2012). Causes of maternal deaths include unmanaged cardiovascular disease, preeclampsia and eclampsia, suicide, infection, hemorrhage and drug overdose (CDC, accessed 2020), often times because of systems failures to keep women insured during the interconception period, disbelief and implicit bias some providers possess and invoke on women of color, especially African American and Black mothers (Taylor, J. et al., 2019) during prenatal care, at labor and delivery, and immediate in-patient postpartum, 18 and within the first 40 days postpartum while mom is at home or at her outpatient postpartum care visits. Despite many quality improvement and program investments, this rate continues to persist. Recent deaths and near misses of higher socioeconomic class African American and Black mothers (e.g. Serena Williams) have woken up the mainstream and researchers to be brave enough to call it what it is – racism – in the health care system that has brushed off issues and complaints, instead of empathically listening, like one would to a White mother. Data and mounting evidence is purporting that racism cross-sectoral, not race, is a key contributor to these sad rates of birth outcomes, infant and maternal mortality (Jones, CP, 2000; Hogan, V. et al, 2012 and 2018; McLemore, M., 2018; Taylor, J., 2019). These data express the need for a more race-specific, culturally humble and attentive, and learning-from approach designed by Black mothers themselves, and not just more assessments and screening without context, linkages in place, or a trusting relationship with mom. Birth Outcomes and Mortality for California and Los Angeles County California Disparities exist in California, as well. As of 2014, the total number of births in California was 502,879 with about half being of Hispanic descent and only 5.6% of non-Hispanic Black descent. Of this approximate 500,000 births, 47.6% of all births in California were paid for through Medicaid (March of Dimes, 2020). Despite the low ratio of births, Blacks in California also have a disproportionate rate of preterm birth (11.9% for non-Hispanic Blacks vs. 7.7% for non-Hispanic whites and 8.3% for Hispanics), low birthweight (11.5% for non-Hispanic Blacks vs. 5.9% for non-Hispanic whites and 6.3% for Hispanics) and infant mortality (9.3 deaths per 1000 live births 19 for non-Hispanic Blacks vs. 3.9 for non-Hispanic whites and 4.6 for Hispanics) (MOD, State Data, 2016). LA County Regional Health Behaviors and Social Determinants of Health (SDOH) Los Angeles County is made up of eight service planning areas (SPAs), with a ninth being for the American Indian population. These regions vary vastly from each other in that some emulate rural characteristics and span 2200 square miles (SPA 1 Antelope Valley) and two have the highest income and highest educated populations with very little pockets of poverty (SPAs 5 and 8). Many of the disparities and inequities in the general population too are still seen most in SPA 1. The distribution of African American and Black and Latino descent population in SPA 1 are 15.3% & 44.3%; SPA 2 are 3.5% & 40.2%, SPA 3 are 3.7 % & 46.3% and SPA 4 are 5.7% & 51.8%, respectively. English language is most often used at home in SPA 1 (76.8%) and SPA 2 (68.7%) while the percentage drops in SPA 3 (50.2%) and SPA 454.4%). The most reported adults with disabilities occur in SPA 1 (29.7%), compared with the other SPAs at 22%, 21% and 24% respectively. The adult population who have a high school or less level of education is highest in SPA 4 (27.3%) and SPA 3 (23.6%) with SPA 1 and SPA 2 at 16.8% and 20.7%. The highest rates of people who are unemployed (and looking for work) are in SPA 4 (12.6%) and SPA 1 (12.4%) while SPA 2 is at 8.8% and SPA 3 is at 9.2%. The percent of people with household incomes less than 100% of federal poverty level are highest in the 4 SPAs DHS will work with when compared to all of the LA County - SPA 1 at 21%, SPA 2 at 14.9%, SPA 3 at 13.3%, and SPA 4 at 24.3%. The highest rate of reported tobacco use is in SPA 1 at 18.2% (SPA 2 12.8%, SPA 3 12.8%, SPA 4 14.1%). SPA 1 has the worst lung and colorectal cancer death rates, and an all-cause mortality rate which is the highest in the county and higher than the national average. Our target SPAs have a low percent of adults who read to their children aged 20 0-5 (SPA 1: 58.8%, SPA 2: 60.0%, SPA 3: 54.0% and SPA 4: 54.4%), or sing to their children daily aged 0-5 (SPA 1: 55.7%, SPA 2: 51.5%, SPA 3: 45.7% and SPA 4: 41.7%). SPA 1 (23.1%) has the highest percentage of children aged 0-17 experience the most special health care needs as compared to all SPA regions, with children aged 0-5 years constituting 9.4% of the total SPA population. These areas are vast and extremely remote; thus, access to affordable food, housing and all support services are the largest barriers experienced by low income adults. They generally travel by bus/Metro Train, if they can afford it, as gas prices are the second highest in the U.S. What is missing from these statistics, however, is the experience of discrimination and racism. LA County Department of Public Health does not collect those data in their annual health status report. As it should, unfortunately, this major predictor and contributor of poor health status and poor birth outcomes cannot be further contextualized for policy makers, planners, researchers, and community advocates. The following data is from the Los Angeles County Department of Public Health population-based surveillance tool called the LAMBs survey and is a proxy for FIMR (Fetal Infant Mortality Review), which asks mothers who recently delivered a baby about events that happened before, during, and after pregnancy. Its objectives are to understand the causes of poor birth outcomes in LA County, and to identify areas where help and resources are needed most. African American and Black and Latina mothers are more likely to not have access to preventative health services before pregnancy when compared to their White and Asian counterparts. Of African American and Black mothers in LA County, 10.9% reported being uninsured before pregnancy and for Latina mothers the rate was more than double at 26.3%. Pre- pregnancy health and well-being, when measured by preconception health counseling and 21 unwanted or mistimed pregnancy, also shows that African American and Black and Latina women carry the highest burden. In the 6 months before becoming pregnant 70.4% of African American and Black moms and 75.8% of Latina moms reported that they did not receive any preconception health counseling from a health care professional about how to prepare for a healthy pregnancy and baby. Among this population 55.9% of African American and Black and 52% of Latina moms said their current pregnancies were unwanted or mistimed. [section reference: LAMBS Report, 2018]. African American and Black moms are 15.3% more likely than any of their counterparts to report cigarette smoking or nicotine use in the 6 months before pregnancy as compared to all women in LA County (7.4%). Nutritional factors, including access to food, is reported as food insecurity 6 months before pregnancy by African American and Black and Latina moms in the highest numbers of 10.6% and 4.5%, respectively. [section reference: LAMBS Report, 2018]. Pre-pregnancy conditions are important to consider as they can be addressed as preconception or interconception markers for pregnancy health. When looking at pre-pregnancy health conditions that are associated with premature birth and low birthweight, the report stated that LA County African American and Black moms are at highest risk for not being in good or excellent health in the months before pregnancy. They are more likely to be obese (61.3%), have high blood pressure (7.6%) and complain of depressed mood (14.7%). The percentages of preterm birth (9.6%, with Latinas close behind at 8.8%), low birthweight (9.6%, and Latina’s at 7.3%) and stillbirth are also highest among African American and Black women. [section reference: LAMBS Report, 2018]. Maternal risk factors during pregnancy are, likewise, considered important because they address markers that can be actively addressed to prevent adverse birth outcomes. As well, 22 managing these successfully during pregnancy will help in managing them once baby is born (postpartum). Many mothers who do not continue treatment risk exacerbating them and predisposing themselves to further risk at a consequent pregnancy. African American and Black (13.1%) and Latina (9.7%) moms are more likely to enter prenatal care after first trimester. They are also more likely to be diagnosed with high blood pressure during pregnancy (16.7%) and Latinas reported at 11.9%. African American and Black moms report higher rates of risky behaviors during pregnancy such as cigarette smoking (5.8%), using illegal drugs or drugs not prescribed by a medical provider (10.8%), and using marijuana (5.7%). Binge drinking alcohol among African American and Black moms were the highest reported group (9.7 %) with Latinas at 8.1%. Linked to struggles in coping abilities, many of these behaviors are products of poor economic advantage and access to upward mobility. Viewing the risky behaviors as larger systemic pressures, government systems are best suited to address oppressive infrastructures related to risky behaviors for any citizen of any race or ethnicity. With more and more studies showing that psychosocial and behavioral factors can contribute to low birthweight, especially in the African American and Black moms, as compared to whites, LA County reported the following factors affecting African American and Black and Latina women more disproportionally: food insecurity (16.8% and 12.4% respectively), depressed mood (35.8% and 27.5% respectively), lack of support by the baby’s father, interpersonal physical or emotional violence (18.5%), experiencing discrimination (53.7%), and hardships during the childhood of the mother. [section reference: LAMBS Report, 2018]. Compared to White (91.3%) and Asian (88.1%) moms, 86.3% of African American and Black and Latina moms report having an adult who believed in her and with whom she could count on; however, despite this protective feature, the rate of depression and chronic disease persists 23 among this population, lending to notions that more value placement by healthcare systems and government alike could provide more socially supportive programming. Also, 17.1% of African American and Black moms had a parent/guardian who when to jail and 9.8% of Latina’s also experienced this childhood event, while 18.9% of Latina’s stated they had a parent/guardian who had a serious drinking/drug problem and 16.3% of African American and Black moms reported the same. A disproportionally high percentage of African American and Black women reported being in foster care at 9.7% compared to 2.3% for all mothers. Of mothers who experienced housing insecurity where they had to move because of problems paying a mortgage/rent, the highest number again was with African American and Black women at 39% and Latinas at 29.3%. Overall African American and Black (32.8%) and Latina (29.3%) moms reported the highest percentages of experiencing two or more diagnosable, traumatic hardships during childhood. Birth Outcomes and Mortality by LA County Service Planning Area (SPA) SPA 1, 2 and 3 cover large geographical areas making it difficult to find quality health care services without long bus/train rides and gasoline expenses. In SPA 1 and 2 the percentage of African American and Black women who have given birth to a low birthweight infant (<2500g) is 14.4% which is almost double the rate for white women (8%). The rate of preterm birth (between 17-36 weeks) is also much higher for African American and Black women (13.3%) compared to whites (8.9%). When looking at entrance into prenatal care, African American and Black and Latina women are less likely to enter prenatal care during the first trimester than their white and Asian counterparts. However, the most important factor is that African American and Black infant mortality rates are 11.6 per 1000 live births and Latina infant mortality is 8 per 1000, while white infant mortality is about 3 per 1000. [section reference: Los Angeles County Department of Public 24 Health, Maternal and Child Health Branch, CA State Vital Statistics source data; Healthy Start Data Query November 2018]. SPA 3 and 4 experienced the same disparities. The percentage of African American and Black women who have given birth to a low birthweight infant (<2500g) is 12.5% where again, it is close to double the rate for white women (6.7%). The rate of preterm birth (between 17-36 weeks) is also much higher for African American and Black women (12.7%) compared to Whites (7.6%). Again, entrance into prenatal care for African American and Black and Latina women is higher in the second trimester at 13.6% and 10.8% compared to whites at 7.4%. African American and Black infant mortality rates are also higher in this area at 10 per 1000 live births compared to the White infant mortality is about 2.3 per 1000. Rates are more pronounced in SPAs 6 and 8. Although not all 44,775 births in these two SPAs are to one race, 19.5% of the total population is African American, more than double the same race population living in in greater Los Angeles (8.3%) (LACDPH Report), and 12.2% of births were preterm and 7.8% were low birthweight – highlighting the importance of tailored, geographic specific care and outreach (California Department of Public Health, Center of Health Statistics, OHIR Vital Statistics Section, 2010. ). Last, specifically to DHS, patients are more likely to deliver with no prenatal care (< 4.3% of the population), as compared to <1.0% at non-DHS institutions. Lack of prenatal care is associated with preterm birth and low birthweight, suggesting that the DHS cohort likely represents a higher risk group of mothers. 25 Summary Health services is not doing mothers, or African American and Black mothers, a favor by offering ‘cookie cutter’ programs that are highly manualized, with no wiggle room for tailoring or adaptation, and not participatory or partnered in approach. Being racially and culturally humble and attentive, empathic and genuinely concerned, and cognizant of her “whole person” (personal physical, mental, social, environmental, spiritual lifecourse history) can form a foundation of trust that precedes any real change. Using an assets based approach to understanding a person assumes that a mother brings her worth to the desired professional treatment relationship. Tending to her needs, acknowledging her strengths, leveraging her opportunities and protective factors, and minimizing/mitigating her threats is what medicine has taken an oath to do for anyone and all who present themselves. Programs that shift the paradigm of perinatal health and put mother first as the primary value add to achieve healthy outcomes are essential to changing outcomes – if mom is not well, then baby is not well. Healthcare systems that best build a model of maternity care that is most reflective of its main actor – the mom - are needed. As such, traditional maternity health care models are lacking in comprehensiveness. Several have evidence to show effectiveness in resolving intermediate level outcomes like managing chronic conditions and basic prenatal metrics; but, the same have limitations in its service provision. The high rates of poor birth outcomes, infant mortality and now maternal mortality seen nationally, statewide and locally highlight the urgency for policy and other decision makers to promote health care systems that make mothers the center of care by redirecting power and focus back to them, thereby levelling out a historically imbalanced and hierarchical, technocratic and impersonal, and racially unaware and unhumble system that is not living up to its 26 mission. These maternal and infant outcomes rates are simply unacceptable in a leading economic nation with resources to ameliorate issues seen every day in developing countries. In the pages that follow, the development and implementation of the MAMA’S Neighborhood program is presented. Chapter 2 provides a review of the relevant literature, and covers the following: 1) Understanding Maternal Health: Description of Each Phase and Importance/stats (reasons for new model) to contextualize the significance for systems improvement and organizational change 2) Social Determinants of Health/SCTH and Birth Outcomes; 3) Program models on maternal child health aiming to improve birth outcomes (gaps noted as case for new model) are compared to show their elements, outcomes and gaps, and consequently, the need for comprehensive programs that deliver precise care plans within a neighborhood, place-based context tailored to disempowered and disconnected mothers; 3) Why CCs specifically are critical to perinatal health outcomes and 4) Frameworks for individual and organizational change to offer ways to approach systems change that is grounded in successful behavioral change. In Chapter 3 and 4, the care transformation arc of a maternity centered medical home model is, then, documented as a potential framework to apply in complex bureaucratic systems of care that struggle to adequately serve its most marginalized pregnant mothers. To ground this diffusion of innovation, Rogers Theory of Diffusion (Rogers, 2003) and Institute for Healthcare Improvement Model for Improvement 4 and Breakthrough Series (Langley, et al, 2009) are described to frame the elements and processes a system or organization progresses through during organizational change. As well, two health behavior change theories (Maslow Hierarchy of Needs and Transtheoretical Model) are discussed to display the overlap in constructs, furthering the 4 The Model for Improvement was created by the Associates for Process Improvement for the Institutes for Healthcare Improvement. 27 support that systems and organizational change are largely dependent on its internal agents of change readiness, motivation, self-efficacy, and “theories in use” (Argyris and Schon, 1996); the health and capacity of the unit; whether an agent of change (champion of change) exists; how willing the organization and its staff are to reflect on itself (360 degrees); and how achievable and meaningful the next stage’s state is as compared to staying in the status quo. Last, Chapter 5 recommendations for refined enhancements are offered to encourage the continual progression towards excellence, the tailoring of care to be equitable, and the commitment to improving birth outcomes. 28 Chapter 2 Literature Review Background Preceding infant mortality are gross morbidities experienced by mothers and babies, such as preterm birth, very low and low birthweight and maternal health complications that can be mitigated through intensive care management in a clinic or home-based environment that addresses both clinical and social determinants. In addition to these, investing in improving the social capital of pregnant and parenting mothers increases the likelihood of maternal and infant positive health outcomes, economic stability and a stronger life trajectory for the infant. Addressing her toxic stress and adverse life events over her lifecourse can contribute to a healthier mom, baby and family (Halfon, Lu 2003; Lu, Kotelchuck, Hogan, Jones, Wright, and Halfon; Lu, MC, 2010 MCHB, HRSA, USDHHS). The Los Angeles County Department of Health Services (herein referred to as DHS interchangeably) is the second largest public health care system in the nation. In 2013, electronic health records had not launched, and population health for care management was nonexistent. Being a Managed Care provider under Medicaid also required compliance with the Comprehensive Perinatal Services Program (CPSP), which it was not at that time. The opportunity for DHS to impact the rates of preterm birth and low birthweight, and therefore, reduce disparities in maternal and infant mortality in Los Angeles was significant. A paradigm shift was needed to make room for a new model of care. At the time, LACDHS needed new leadership at the very top, and specifically in women’s health, which had not had its own unit. Previous efforts predating the DHS Women’s Health Programs and Innovations unit’s creation addressed women’s health from an urgent emergent 29 medicalized perspective, hierarchically and without culture or race/ethnicity in mind. DHS had devolved into a system that was responding to crisis in pregnancy and postpartum, rather than proactively providing preventive perinatal services designed for the whole woman. Pregnant women were all seen by specialists, instead of as needed; OB/GYN generalists were not used routinely; only medical residents were utilized for frontline care; and nurses who supported them asked questions of some patients with no structured assessment scales or consequent care planning that included verified, linked community referrals. Collaborative Care case review and the IMPACT Model (University of Washington, 2011; Conway and Clancy, 2009) were not used (multidisciplinary); patient review was solely reviewed by physicians and medical residents, not social or mental health specialists. It was financially and programmatically inefficient and ineffective in proactively addressing the known predictors or contributors of poor birth outcomes. The methods of assessment and care planning were not evidence based to complement the evidence based obstetric medicine it was providing. As a new DHS Director of Health Services took his place, Dr. Mitchell Katz reorganized its intentions toward community based medicine principles that took a more collaborative approach to decision making, involved community based organizations and landscape leaders in policy change and service delivery, and mandated the usage of licensed professionals to be used at the top of their license. With these directives, new, progressive Executive Directors/Managers were recruited to be those agents of change to draft new strategic plans to address the adverse disparities seen in County DHS constituents. Thus, a new department was established in 2011 called the Women’s Health Programs and Innovation (WHPI) department whose goal was to organize and improve primary, secondary and tertiary women’s health service delivery over the lifecourse with the lens of community based decentralized medicine, prevention and mother- 30 centeredness. As such, its new Director, Dr. Erin Saleeby, set out to apply its new funding from the Center for Medicaid and Medicare Services, Innovations Branch, to develop a strategic plan to reduce poor birth outcomes. This funding required WHPI to ask very challenging questions about its values, strengths, weaknesses, alignments and goals, and its outside threats that could make improvement not only hard, but impossible. The program awarded was nationally called, Strong Start Initiative for Mothers and Newborns (Strong Start), and locally branded as, “MAMA’S Neighborhood” which stood for, Maternity Assessment Management Access and Service synergy throughout her Neighborhood for health (MAMA’S). With its multiple objectives to expand upon principles of the patient centered medical home, MAMA’S goals were to offer: 1) service provision by care teams, improving both care coordination and patient access; 2) patient-centered care management services for high-risk women, with service intensity determined by risk-score; 3) Health Information Technology (HIT) utilization for population management; and 4) continuous quality improvement processes to track process and outcome measures and support rapid-cycle improvement. Additionally, MAMA’S aimed to enhance the content of prenatal care by actively engaging community organizations in the plan of care, creating a true ‘Neighborhood’ for health. These content enhancements include interventions for: 1) substance use- smoking, alcohol and drug use; 2) social stability- food and housing scarcity; 3) mental health- depression, intimate partner violence; and 4) biomedical risk using telemedicine. Chapter 2 Overview In this chapter, a review of the literature discusses the importance of building and implementing a model of care grounded in readiness, resilience and relationships, rather than compliance, deficit and outcomes. Health care organizations are in dire need of remodels to reflect 31 its service populations’ needs, and to move away from blaming the victim (Scott, KA, Britton, L, McLemore, MR, 2019). Perinatal health programs, importance of reproductive phases as they relate to care design, and organizational improvement models will be presented to make the case for innovation in care design. First, literature is reviewed on the facts and issues mothers face during three perinatal phases, the impact of race and racism on these perinatal phases, and large- scale programs that are addressing the adverse rates of perinatal health outcomes. Next, models and strategies of organizational and individual level changes are reviewed to offer how to support readiness to change and resiliency, and why organizations must evolve themselves to be responsive/reflective, responsible and equitable in their structure to be a sustainable leader in healthcare. Race, Racism and Health Disparities Overview Health disparities are generated from mechanisms become disparities because of the oppressive, supremist structures and systems that empower them to stay intact. The US Health and Human Services produced a progress report that addressed reducing racial and ethnic disparities in 2015 with the understanding that structural systems could do much better to remove the barriers that prevent advancement for marginalized people that has occurred as a result of poor oversight, planning and acknowledgement that antiquated policies have continued to oppress different racial and ethnic groups and led to poor health outcomes. However, even though these initiatives have been implemented, disparities remain from the differing socioeconomic conditions, called the social determinants of health. The Institutes of Medicine Committee on Understanding Racial and Ethnic Disparities in Health Care also have tackled this dilemma, calling 32 out structural policy changes that are needed to support different implementation of care from insurance providers, clinicians, community-based organizations and social care entities (Smedley, BD, et. al 2003; IOM, 2003; Satcher, D, 2000; IOM, 2012). For decades, the US’ health care delivery system has left out key aspects of changing health outcomes, including translating knowledge into practice, focusing on building trusting patient-provider relationships, tailoring interventions to be racially and ethnically based, and bravely implementing care that does not further marginalize groups with generations of trauma with institutions. Strategies such as improved digital structures, clinical decision support, patient centered care, community linkages and joint planning efforts (Israel, B., et. Al. 1998, 2005; Wells, K., et al, Jones, L., et al, 2007), continuous quality improvement, care continuity, and changing policy have been recommended as best practices, yet minority groups still suffer the worst health outcomes (IOM, 2012). Consistently, the IOM calls for infrastructure that promotes the best care at lower cost to produce better health outcomes; however, they and other institutions, although meaning well, have not boldly called out what may be underlying much of the problem: antiquated structures that promote division rather than empowerment of all people, especially African American and Black peoples. They call for more patient centered care and tailored interventions but do not put the accountability policies in place that would encourage systems to change. Calling on community integration of changing the wellbeing of marginalized groups is an important strategy, but alone, as it has been for some time, change cannot be done. A partnership of health between heath care institutions, frontline clinicians, and racially and ethnically mindful policies is needed. To begin to understand how disparities continue to exist, one must be open to the notion that it is not being a certain race that perpetuates poor health outcomes, but rather the social structures that house those various races. For centuries and even up to the 20 th century, researchers 33 posited that innate biological differences amounted to why African Americans and Blacks experienced disease at higher rates (James, S., 2009). Epidemiologists aggregated data controlling for various demographics to try to make sense of the etiology of diseases, only to see still that certain minorities were still experiencing disease at higher rates. The origins of these etiological hypotheses, like many issues, however, were clouded by societal norms of white superiority, rather than being completely objective and reflective (Ford, C, Airhihenbuwa, C, 2018). In more recent decades, more conscious researchers have applied a more multifactorial method to understanding disease, helping some in recognizing the disparities and contextualizing the nuances associated. James cited both Braveman’s and Whitehead’s term “health disparities” as a term that should refer to group differences in health that were, “unnecessary, preventable, and unjust,” and he extrapolates Braveman’s further operationalized definition to be: “A health disparity/inequality is a particular type of difference in health or in the most important influences on health that could potentially be shaped by policies; it is a difference in which disadvantaged social groups (such as the poor, racial/ethnic minorities, women, or other groups that have persistently experienced social disadvantage or discrimination) systematically experience worse health or greater health risks than more advantaged groups” (James, S., 2009; Braveman, P., 2006). More directly, in the last ten years, Ford and Airhihenbuwa developed a framework for Critical Race Theory (coined by Derrik Bell in 1973, Crenshaw, K. Delgado, R, Ladson-Billings, ) in Public Health called the Public Health Critical Race Theory Praxis (PHCRTP) that now guides research methods and interpretation of their findings with a lens unseen before which lifts up race, marginality and equity (Ford and Airhihenbuwa, 2010, 2018). Similarly, Hogan, V, et al, in 2018 created a framework (R4P) that also integrates CRT and intersectionality, and indicates five components (Remove, 34 Repair, Remediate, Restructure and Provide) to assist in translating associations and causality into public health equity policy, planning and development research tool (Hogan, V, et al, in 2018). As a result of this closer examination of disparities, public discourse in public health arenas has continued, and with efforts such as PCORI (Patient Centered Outcomes Research Institute) have aimed to address racial disparities head on with communities and translate them together to change the popular narrative. This advocacy research has led to the calling out of racism and its associated structures as the culprits for these poor outcomes, prompting policy makers (although slowly) to go into deeper reflection of what it needs to do if change is truly desired (Jones, CP, 2000). Integrating together institutionalized racism, personally mediated racism, and internalized racism, this influential paper tells the story of a garden if minded differently (with more empowerment, access and promotion) could yield different results; and if not, a slow denigration of self, immobilization among groups, mentally lazy society, and inequitable structures end up being perpetuated (Jones, CP, 2000). Focusing policy efforts on shifting the paradigm of ‘blaming the victim’ to ‘keeping structures accountable for its people’ is where researchers (Geronimus, A; Mosley and Chen; Lu and Halfon; Wells, Norris, and Jones; James, S; Braveman, P.; Hogan and Rowley; Parker-Dominguez, T; Collins, J and Williams, D; Ford and Airhihenbuwa, C., and many more) are moving the dialogue, holding steadfast that acknowledging and dismantling oppressive structures is part of adaptation and evolution in health and society, not giving unworthy groups a ‘pass.’ And, now, with social media now integrating itself in health promotion programs as integral to reaching populations of interest and populations of the ‘uninterested’, a light is shining more brightly on structural inequities lying at the base of these socioeconomic and health disparities. Health inequities are rooted in multidimensional causality, and overturning them will require a 35 multisectoral approach, examining and reporting the connected factors and stories of the most affected populations, and holding systems accountable for operationalizing sustainable changes. Oppressive socioeconomic systems contribute to chronic stress at the individual level, which can lead to increased inflammation in the body. Inflammation is at the physiologic root of many diseases. African Americans experience these chronic conditions at much higher rates than other racial and ethnic groups (CDC, 2020). One such poignant hypothesis that exists in public health research is, “John Henryism,” (James, S, 2009). It suggests that, “repetitive high effort coping with social and economic adversity is a major contributor to the well-known excess risk among poor and work class African Americans for hypertension and related cardiovascular diseases,” (James, S. 2009). As a result, African Americans are paying a heavy price for the coping required to ‘get by’ or ‘succeed’ or ‘be seen’ in a white dominated world. There is a constant threat of technological advances and insecurity of not being able to keep up because of poverty. The hypothesis is emblematic of the hardships that many African Americans may feel they must do to carry on, but, this constant struggle and suppression of adversity is toxic to the body, and has put this population at greater risk for disease and disability. Although there may be successful strategies used to cope in major strife among African Americans that the world could all learn from, the pervasive forces of marginalization and “John Henryism” leave African American families struggling to live their lives with dignity. Perinatal Phases and Their Significance Why Does Pregnancy Matter? The perinatal period is defined as the time of conception to one year after birth. This period is highly influential for a mother as many changes and transitions are to be made to support a 36 healthy pregnancy and eventual motherhood adjustment once baby is born. Midwifery systems of care have traditionally been holistic in nature, lending themselves to better birth outcomes and higher patient satisfaction (Urban Institute, 2018; HRSA, MCHB, 2018). Although much of care is not in these nontraditional settings of birth centers and group prenatal care because of how the US funds its healthcare, those states with payor systems that allow for non-traditional settings assist mothers of any economics to have choices in perinatal care. These nontraditional settings also elevate a mother’s autonomy in decision making much higher than traditional settings with antiquated designs (Alliman, et al, 2016; McIntyre, MJ, 2012; Grigg, et al, 2017). Pregnancy is often a time seen as a ‘window of opportunity’ behavior change for the better for both mother and child. However, mothers often have multiple life stressors to address that can negatively impact her pregnancy’s health. For many pregnant women, these life stressors may be manageable; but, for others, chronic stress becomes toxic physiologically because their bodies remain on constant high alert, versus, having lengthy periods of recovery that allow bodies to heal. Pervasive and impactful social issues like exposure to violence, no to slow economic advancement, lack of affordable housing and sometimes insecure social network, can have strong effects on mental health, a feeling of empowerment and hope – all very much associated with chronic stress. As well, a social issue beginning to show itself more overtly in the literature is racism for African Americans and those of Black descent and its effects on health during pregnancy, and separately to the adult population’s health status. These stressors often lead to adverse maternal health and a poor birth outcome, especially in women of lower socioeconomics and African American/Black race (Lu, MC, Kotelchuck, Hogan, Jones, Wright, and Halfon, 2010). In an article discussing the social context of reproductive disadvantage, it recommends that for over 100 years African American mothers and children have had the highest rates of maternal and infant mortality and 37 morbidity (preterm birth and low birthweight); and that perhaps now is the time to explore macro level factors such as racism, oppressive systemic structures and the deeply rooted issues or race based socioeconomic status as causal reasons for poor reproductive outcomes (Parker-Dominguez, 2011). Stressors can include one or many of issues listed below; studies attached to these inequalities are mentioned. Although non-exhaustive, these articles point to data that exemplifies the inequities in systems in America that contribute negatively to advancement for racial and ethnic groups. ▪ proximal or distal/structural racism such as: o racial residential segregation (exposure to racial residential segregation for Black mothers was associated with increased risk of preterm birth [OR = 1.26, 95% CI = 1.10, 1.26]) (Mehra, et al, 2017); o redlining in home ownership (Black loan applicants in Philadelphia County, PA were almost 2x more likely to be denied a mortgage loan compared to White applicants (OR = 2.00, 95% CI = 1.63, 2.28 and OR = 2.26, 95% CI 1.98, 2.58] (Mendez, DD, Hogan and Culhane, 2011); (Preterm birth rates were higher in Blck women living in redlined areas versus non-redlined areas (18.5% vs. 17.1%) in Chicago, IL between 1989-1991 [OR=1.08, 95% CI = 1.03, 1.14 for redlined; OR= 1.12, 95% CI= 1.04, 1.20 for non-redlined] (Matoba, Suprenant, Rankin, Yu and Collins, 2019). o Overt discrimination: Numerous studies have shown that different health indicators have been associated with racial and ethnic discrimination, such as, depression, stress, anxiety, hypertension, self-reported poor health, breast cancer, obesity, high 38 blood pressure, and substance abuse (Williams, DR, et al, 2003; Pascoe, EA et al 2009). ❖ A recent poignant study published in the Journal of Racial and Ethnic Disparities reported that even higher SES Black women had a higher risk of preeclampsia, and shorter gestational length births (Ross, et al, 2019) , suggesting that race and systemic racism need to be examined and deconstructed loudly yet rigorously so that policy makers and regulators are held accountable for designing a more equitable healthcare system for ALL women. ▪ Paternal socioeconomic disadvantage: low paternal socioeconomic position is a new risk factor for predicting/associating low birthweight in infants independent of maternal demographic characteristics. Infants born to fathers with lifelong high socioeconomic position had a low birthweight rate of 3.7% vs. lifelong low socioeconomic position was 9.3% (Collins, JW, et al 2016 and 2019). ▪ food insecurity; two in five low-income adults are unable to afford enough food (CDPH, accessed 2020; ) ▪ lifelong exposure to discrimination: constant chronic stress due to accumulated discrimination can have a damaging weathering effect on physiological processes that when experienced as racial discrimination among African American women lead to it being delineated as an independent risk factor for preterm delivery (Collins, JW, et al, 2004; Parker-Dominguez, T, et al, 2008) 39 ▪ housing instability; African Americans and Latinos spend over 30 percent of monthly income on housing, making cost of living high and quality of life low. (CDPH, accessed 2020; Moore, LV et al, 2008) ▪ insecure financial stability; one study mentions that African Americans fall behind all other demographics in annual household earnings (DeNavas-Walt, proctor and Lee, 2005) These stressors have been categorized as some of the social determinants of health in the public health/health science literature. Although they may not ‘determine’ a pregnant mother’s birth outcome or wellbeing postpartum, these stressors can ‘contribute’ to poor outcomes for mother and baby, and are usually transgenerational, which can make them difficult to unravel and toxic (cite). Harvard established its Center for the Developing Child, where it explains toxic stress’ beginnings in the womb for a fetus, but also its effects on maternal health. As well, in more recent years, research has associated maternal-fetal health to an increased rate of poor health indicators for mother over her lifespan (between pregnancies and in her post-menopausal years), and during the lifespan of the infant (Arabin, B et al, 2017). It is during this interaction during pregnancy and postpartum that building a trusting relationship with one’s care provider is critical because the basis of any help is dependent on the quality of that relationship. The “serve and return” that may have been absent in a woman’s younger years may play a role in her ability to cope with stressful life circumstances later in her lifecourse, putting her at higher risk for physical and psychological adversities (Maternal Mental Health Now, accessed 2020). The normal peaks and valleys of a normally functioning regulatory response system are not there when a maladapted recovery system is existent – the state for the brain and the rest of the body is to stay at those high peaks or low valleys, which initiates and retains inflammation in the body and produces disease. To alleviate that toxic stress and buffer those peaks and valleys, daily 40 healthy supports are necessary, especially during pregnancy and postpartum. For pregnant women, some of this healthy support can come from her immediate family and/or community and health care providers. Maternal mental health is of great concern in health care in the last 20 years. Rates nationally estimate that one in seven new mothers suffers from postpartum depression. And in California, one in five women giving birth experienced either prenatal or postpartum depression in 2013 (Wisner, K, et al, 2013). Untreated, it has been linked to inconsistent prenatal care, substance use, development of chronic health conditions and preterm birth (Grote, N, et al, 2010). Mothers who were depressed during pregnancy are 60% more likely to report depression in the postpartum two years postpartum than those who were not depressed during pregnancy who had a rate of postpartum depression of 27% (LAMBS Study, LACDHS, 2014). Again, disparities prevail in African American mothers vs there Latino and White counterparts, whereby the LAMBS study reported 74.4% of African-American, 61.4% of Latina, and approximately 46% of White and Asian/ Pacific Islander mothers reported depression more than two years after giving birth if depressed during their pregnancy (LAMBS, LACDHS, 2014),. Overall, in this survey of nearly 125,000 women, 47% of all women of any race or ethnic background reported depressive symptoms after pregnancy. In 2019, the California Department of Public Health and CMQCC and Public Health Institute produced shocking findings regarding maternal mental health as it relates to pregnancy associated suicide. It studied 99 maternal deaths from 2002-2012, 83% of mothers died in the late postpartum period (42 days – 1 year), with 36% of those dying between 43 days and 6 months (CDPH, 2019). The study also noted that 62% of women had reported a mental health condition before becoming pregnant, and 23% reported a history of metal heath conditions. Among the most prevalent in diagnosis were depression (54%), psychosis (24%) and bipolar 41 disorder (17%), with substance abuse disorders comorbid among all mental health conditions noted. Over one third were using illicit drugs including opioids, and substance use was noted as the precipitating factor among 29% of them. 85% had psychosocial stressors indicated, which confirms again that not only assessing with genuine intent to treat but doing so carefully within a relationship-based framework is critical to unveiling trauma, risk factors and courses of treatment for those with high-risk of adverse postpartum mental health. Over half of the mother’s charts reviewed had a good to strong change of preventable suicide and showed missed opportunities to intervene. Sadly, again, we don’t know what we don’t know – so, a mother centered model that allow for close relationships to be built in the prenatal with peer relatable personnel like Care Coordinators, Home Visitors and Doulas, along with empathically driven clinicians will serve very useful in anchoring mom and family in the postpartum. If the health care system is seeking to intervene with a pregnant mother, it is then necessary to focus on the whole woman and her past, present and future. The Women’s Health Continuum model and Lifecourse Model (Lu and Halfon, 2003) displays that there are distinct points in her life where life changes occur. Lu and Halfon’s model contextualized a woman’s whole life while pregnant, giving weight to her history of reproductive and social events, and environmental and structural stressors in her life; and thus, lending strong associations of these social determinants of health as potential toxic stressors (or protective factors) capable of producing a preterm birth or low birthweight baby (Lu and Halfon, 2003). In this review, many aspects of health were stated as related to preterm birth, however, one aspect was lifted up as a critical element not adequately accounted for in traditional prenatal care – structural racism and implicit and explicit oppressive systems that broken trust with African Americans and Blacks in the US over centuries, and thus, continuously marginalized them (and other communities of color, Hispanic/Latinos, Native 42 Americans) from receiving unbiased, empathic care. While prenatal experience will not alone change outcomes, expanding this empathy to healthy supports in her community may result in a protective effect on her health. Embracing her whole person allows the mother to be fully acknowledged, allowing for slow build of trust to begin between her and the provider, and hopefully, the opportunity to mitigate chronic pressure that increase her risk of adversity. Embracing in a perinatal health care setting can be through a system that frames its work on building trusting relationships with its mothers, providing multidisciplinary care, holding its staff accountable for questionable conduct, and designing programs that espouse shared decision making, leveled power, facilitative guidance, and maternal autonomy. This embrace can assist in mitigating penetrative psychosocial stressors unhealed and sometimes uncontrollable. When life circumstances are uncontrollable (economic fluctuations, structural racism, natural disasters) and repeated, adults fall prey to learned helplessness behaviors and hopelessness (a descriptor of depression) and/or overcompensation (anxiety). Violating that trust in provider-mother relationship can leave mothers feeling disempowered and reinforce feelings of distrust for the system. Perinatal health care providers of all levels have a responsibility and oath to parse out multiple disease pathways (medical and psychosocial), leverage and link support for her to improve what she can through incremental change. Cohen, et al describe psychological stress as occurring, “when an individual perceives that environmental demands tax and exceed his or her adaptive capacity,” (Cohen, et al, 1995; Cohen et al, 2007). The brain is the most important organ in such stress responses. Not uniform in nature, stressful experiences are a part of an adult’s regular life and in this state of allostasis can be more plastic (McEwen et al, 2011). However, over time (or generations) continued exposure to these toxic stressors and resultant ill neuroendocrine responses, creates a toxic state for the brain, called 43 “allostatic load” and which become maladaptive and less plastic or mutability (McEwan et al, 2011). Allostatic load is defined as the, “wear and tear on the body and brain that results from chronic dysregulation (overactivity or underactivity) of the mediators (HPA, autonomic, metabolic, immune) of allostasis,” (McEwen, 2011). Essential to homeostasis, properly functioning mediators during allostasis is critical as one interacts with its environment and changing behavioral states registered by the brain (McEwen, 2011). To combat these toxic life stressors, the literature describes repair through leveraging of protective factors and building of resiliency. It can be argued that many adults have not repaired many transgenerational or single life ills, and not having social supports and internal skills to lean on can exacerbate as one ages and present during pregnancy. Pregnancy initiates a response in women to create a secure environment for herself and baby to grow and live. Without internal and external securities, a woman can suffer, which begins a cascade of stress response hormones that place her and baby at risk for adversity (Dunkel Schetter, C, 2011). In early child development theory, an absent, unreliable or inappropriate response loop from a primary caregiver (mother, usually) can lead to a failing brain architecture. Similar lack of responsiveness from adults in a woman’s (or adult’s) life can continue to harm the brain and ability for her to cope – her stress response is thus always on high alert and continuing to add to her allostatic load (Harvard, Center for the Developing Child, 2015; Dunkel Schetter, C 2011). I. Doulas (Lay Health Advisors) and Maternal and Infant Health No programs have actively incorporated Doulas of any kind into regular perinatal health care. Doulas have largely been used in more affluent communities, although its roots sit in Africa, Eastern countries and Greece. Given their focus on psychosocial issues via support and education, 44 Doulas are a natural fit in perinatal care, and more so a fit for African American and Black mothers due to maternal and infant mortality disparities, the history of birth in the US for African Americans and Blacks, and specialized training in intense emotional as well as care coordination support. Health promotion and disease prevention programs that utilize Lay Health Advisors (LHA) of different types have increased tremendously in recent years. Both cost benefit, and the LHAs more humanistic connection to consumers contribute to this increase. Programs using LHAs have demonstrated decreased cancer rates and chronic health conditions, relapse to drug and alcohol use among chemically dependent individuals and increased recruitment, retention and participation in empowerment research studies. During times of vulnerability, studies have shown that LHAs were essential in instilling trust and activating the change of behavior needed to minimize adverse health outcomes (Eng, et al, 1993; Earp, JA, Flax, VL. 1999; Earp, JA., Viadro, CI., Vincus, AA., Altpeter, M., Flax, VL., Mayne, L., Eng, E. (1997 Aug); Koebetz, E., Vatalaro, K., Moore, A., Earp, JA. (2005 July); McQuiston, C., Choi-Hevel, S., Clawson, M. (2001 October). The Doula, a version of the LHA, has been revived in the last 20 years as a provider of non-medical, psychosocial support during the perinatal period. Ancient Greek for “woman caregiver”, the Doula’s natural helping abilities supports the woman through labor and childbirth, building strong bonds with community women. Unfortunately, fiscal pressures on the medical system moved nurses from providing support and comfort to a more diagnostic role, leaving a gaping hole in the psychosocial care of the woman during parturition. In 2002, Hodnett, et al., published findings that continuous support during labor by a registered nurse did not reduce the rate of Cesarean delivery as opposed to the presence of a Doula. In addition, the Cochrane Database Review revealed that a less pronounced effect was seen when continuous labor support 45 was offered by the health facility member (Hodnett, ED., Lowe, NK., Hannah, ME., Willan, AR., Stevens, B., Weston, JA., et al. (2002); Hodnett, ED., Gates, S. Hofmeyr, GJ., & Sakala, C. (2005). which provides further support that intimate experiences call for intimate interventions by a trusted individual such as the Doula. Social Conditions and Social Stressors The elimination of health disparities in medicine among a nation’s racial and ethnic groups requires entities to work less in isolation and more in partnership and collaboration to create sustainable solutions. Innovative ways to reach, recruit, and retain disenfranchised groups are necessary as exemplified by non-traditional partnerships and paraprofessional care that serve diverse consumers in community in a culturally/linguistically competent and participatory fashion (Dennis, BP., Neese, JB. (2000). Using a Doula as a step in between the medical professional and the woman is principally based on building and maintaining authentic partnerships built on mutual respect, equity in decision making or “win-win”, and knowledge exchange as means of communication. Having a Doula present during the pre and postnatal periods may overcome potential mistrusts between the woman and her medical providers. Wallerstein, a prominent research in participatory research, states that a “lack of control often generating a sense of powerlessness is a risk factor for disease…that empowerment education is necessary to effectively promote health” (Minkler M., Wallerstein, N. 2003; Wallerstein, N. 2006; Israel, BA., Schulz, AJ., Parker, EA., Becker, AB. 2001). 46 Social Stressors and Development of Depression/Anxiety Findings from a recent study performed by Bifulco et al on attachment style and perinatal depression by way of using the Attachment Style Interview (ASI) revealed that insecure attachment style was related to more adverse social conditions: to lower social class and unemployment, being single or cohabiting, having less support and few social contacts, and more disrupted childhood experience. Insecure attachment style was associated with antenatal and postnatal depression, and exhibited avoidant styles (angry-dismissive or withdrawn) in the antenatal period and anxious styles (enmeshed or fearful) in the postnatal period (Bifulco, A, Figueiredo, N, Guedeney, L, Gorman, LL, Hayes, S, Muzik, M, Glatigny-Dally, E., Valoriani, V, Kammerer, MH, Henshaw, CA, and the TCS-PND Group (2004). This was statistically significant across all nine sites globally that participated in the study. Use of a “maternal buddy” or Doula during this potentially physically and emotionally vulnerable time may assist in 1) mediating avoidant and/or anxious styles during ante/postnatal times, 2) provide an intervention model for those with these styles of attachment, 3) increase breastfeeding and other forms of bonding essential to physical and emotional health for the baby, and overall 4) assist in supporting positive birth outcomes and reduced mental stress of the mother and her baby. Doula and Stress and Attachment In a study conducted by Ginger Breedlove CNM, culturally matched community-based Doulas were used to mediate stress with and to prepare disadvantage adolescent women for pregnancy, labor, and the postnatal. Perceptions were documented through this process, and results in positive reports of increased supportive network Breedlove, G. (2005). Additionally, Langer et al, during a randomized control trial, displayed that psychosocial support by Doulas had 47 a positive effect on breastfeeding and duration of labor. The group went on to mention other conditions that could perhaps have limited its outcomes: strict routine in hospital procedures, the cultural background of the women (stigmas), the short duration of the intervention, and the profile of the Doulas (Langer A, Campero L, Garcia C, Reynoso S, 1998). Therefore, with different settings, it may be possible to suspect in future studies a larger effect on medical and psychosocial outcomes if these confounders were controlled for. Alternatively, Escobar et al reported results from a randomized control trial comparing home with Doula vs. hospital intervention, that mothers in the home visit group were more likely than those in the control group to rate multiple aspects of their care as excellent or very good. These included the preventive advice delivered (76% vs 59%) and the skills and abilities of the provider (84% vs 73%). Mothers in the home visit group also gave higher ratings on overall satisfaction with the newborn's posthospital care (71% vs 59%), as well as with their own posthospital care (63% vs 55%). The estimated cost of a postpartum home visit to the mother and the newborn was $265. In contrast, the cost of the hospital-based group visit was $22 per mother- infant pair; the cost of an individual 15minute visit with a registered nurse was $52; the cost of a 15-minute individual pediatrician visit was $92; and the cost of a 10-minute visit with an obstetrician was $9213 (Escobar GJ, Braveman PA, Ackerson L, Odouli R, Coleman-Phox K, Capra AM, Wong C, Lieu TA. , 2001). For higher risk women (medical risk, high stress, previous histories of depression, etc), this may provide more return on investment, as high-risk women tend to utilize services more and be at risk for adverse developments during this time. Ekstrom et al from Sweden reported that women at three months postpartum (in both intervention assigned and control groups) through their understanding of the infant was better, they perceived more strongly the infant as their own, and they enjoyed more breastfeeding and resting 48 with the infant (attachment). Although no statistical significance was seen between the intervention and control group at this time, the intervention group: talked more to their infant, perceived their infant to be more beautiful than other infants, and perceived more strongly that the infant was their own than did the mother in the control group at 9 months observation. Mothers felt more confident with the infant and felt the infant to be closer than did the mothers in the control group (Ekstrom A and Nissen E, 2006). Finally, Grote et al in Pittsburgh used a “risk and resilience” framework to study the effect of optimism during pregnancy with the development of less postnatal depression, controlling for antenatal depressive symptoms. With married women in first parenthoods, they found that optimism of expectant mothers during pregnancy was associated with decreased depression severity at six months and 12 months postnatal. They recommended interventions be conducted with women to assist them into motherhood more seamlessly through culturally relevant social work practices (Grote NK and Bledsoe SE, 2007). Stress and Biology According to the Health Field Model put forward by Evans et al (Evans RG, Stoddart GL. (1990) and documented in the LA County Healthy Births Initiative Blueprint (Los Angeles Best Babies Collaborative, 2005. p.25), birth outcomes are a product of not only of prenatal care, but also a multiple of biological, psychological, and environmental determinants. Individuals responses to events, including stressful ones, are determined by these and individual behaviors and biology. Other researchers, such as Bronfenbrenner, Lu & Halfon and Mosely and Chen support this socio-ecological approach to understanding multi-level health care delivery as essential to 49 improving health and community, as well and birth outcomes (Brofenbrenner, U., 1979; Lu MC and Halfon N., 2003; Mosley and Chen, 1984). There is also rigorous empirical evidence showing the biological relationship of fetal exposure to stress, anxiety and depression to adverse and vulnerable psychosocial and neurocognitive development in newborns and children (Van den Bergh, BR, Mulder, EJ, Mennes, M, Glover, V. (2005); O’Connor, TG, Heron, J, Golding, J, Glover, V and the ALSPAC study (2003). O’Connor et al. also revealed that if a mother is stressed or anxious while she is pregnant, the newborn is more likely to be anxious, have symptoms of attention-deficit/hyperactivity and have lower scores on the Bayley’s Mental Developmental index (O’Connor, TG, Heron, J, Golding J, Beveridge, M, Glover, V. (2002). These outcomes were independent of the mother’s postnatal mood state and child’s environment. Stress of delivery and the early stress experienced by a preterm baby can have effects, for at least several months after birth, on the baby’s own cortisol stress responses (Miller, NM, Fisk, NM, Modi, N., Glover, V (2005). Gitau et al and Teixeira et al further showed that if the mother is anxious during pregnancy there is less blood flow to the baby, and that there is a strong correlation between maternal and fetal cortisol levels Gitau, R, Rish, NM, Cameron, A, Teixeira, J, Glover, V. (2001); Gitau, R, Adams D, Fisk NM, Glover V (2005); Gitau, R, Adams D, Fisk NM, Glover V (2005); Gitau, R, Cameron A, Fisk NM, Glover V. (1998); Teixeria, J, Fisk N, Glover V. (1999). More specifically, past research suggests that prenatal stress, anxiety, and elevated levels of maternal plasma corticotrophin releasing hormone (CRH) are associated with preterm delivery in humans and animals, individually researched. Mancuso et al (Hobel and Dunkel Schetter) measured these variables together and documented that women with a high CRH level and high maternal prenatal anxiety at 28 to 30 weeks gestation delivered earlier than women with lower CRH levels and maternal prenatal 50 anxiety. Also, women who delivered preterm has significantly higher rates of CRH both at 18 and 20 weeks and 28 to 30 weeks gestation (p<.001) compared with women who delivered at term. Thus, psychosocial and neuroendocrine factors to birth are linked factors that can produce positive birth outcomes (Mancuso RA, Dunkel Schetter C, Rini C, Roesch SC, Hobel C; 2004; Hobel CJ, Dunkel Schetter C, Roesch SC, Castro LC, Arora CP. 1999 Jan). From a physiologic standpoint, Melon, et al at Tufts University found that an inability to suppress stress induced activation of the HPA axis during the peripartum period led to a higher likelihood of presentation of postpartum dysfunctions, suggesting that this malfunction was not just behavioral but penetrative to a pathophysiological level (Melon, et al, 2018). Furthermore, Davis et al just published finding in June 2007 stating that prenatal exposure to maternal stress at 30-32 weeks gestation has statistically significantly negative consequences for the development of infant temperament as measured using the Infant Temperament Questionnaire, as well as prenatal or maternal depression and anxiety predicted infant temperament (while controlling for postnatal maternal psychological state) (Davis EP, Glynn LM, Schetter CD, Hobel CJ, Chicz-Demet A, Sandman CA. 2007 June; Taylor, A., Atkins, R., Kumar, R., Adams, D., Glover, V. (2006 July). Feldman, Dunkel-Schetter, Sandman and Wadhwa found strong associations between positive maternal social supports during pregnancy and birth weight by way of fetal growth rather than timing of delivery (Feldman et al 2000), and later Dunkel Schetter published a review on psychological processes during pregnancy that confirmed studies that reported an impact of chronic stress on producing adverse birth outcomes, as seen more so in lower socioeconomic groups and even more in African American and Blacks. As well, pregnancy anxiety was highlighted as more noticeable in pregnant women and may be more of a predictor of depression than originally thought (Dunkel Schetter, C, 2011). 51 During the third trimester, physical ‘showing’ of the baby’s growth is very apparent. This physicality begins the bonding prenatally between the woman and her fetus. Social support may come in stronger at this time as well, whereas family and friends begin to show signs of support to the woman physically and mentally. Also during this time is when the fetus’ growth and brain development are very much at risk, which suggests reason for positive social support, empowerment, and nutrition. Building interventions that build a relationship and bond between a woman and a Doula or ‘maternal buddy’ prior to the third trimester is necessary in providing the most supportive psychosocial environment for the woman. It also suggests further, that in alignment with current efforts and research, involving Doulas preconceptionally (prior to getting pregnant) may be a way to intervene in negative environments or supports to divert poor birth outcomes for mother and baby, including attachment (Cohen & Slade, 2000; Siddiqui & Hagglof, 2000; Schore, 2001). Many researchers have established that the quality of the mother's representation of her unborn child are linked to her own early attachment relationship, that this representation, acting at subconscious levels, has a profound impact on ensuing postnatal attachment exchanges, and that “maternal prenatal attachment is associated with postnatal maternal involvement in the infant-mother interaction” (Siddiqui, A., & Hagglof, B. (2000). Why Does Birth Matter? Overview/History Labor and childbirth has become medicalized in the past century. The advent of technology has removed the caring hands during labor and delivery and focused itself more on diagnostics. Although many life saving medical methods have been developed (augmentation, forceps, cesarean section delivery) to keep mother and baby alive, there is concern that these methods are 52 being overused without yielding results (ACOG, 2014). Davis Floyd describes health care paradigms in three ways that can affect childbirth and all it encompasses; they include the technocratic (mechanistic, separation of body and mind from event, evidence based) , humanistic (lower emphasis on robotic solutions, relational, compassionate, non-separatist, system-person balanced, respects highly informed consent, evidence based) and holistic (oneness of mind and body, mind power on body processes in healing, evidence based, person) models of care (Davis Floyd, 2001). Patriarchal ways of power and decision making in US perinatal care have replaced ancient ones where midwives and women tended to other women. Regulations and litigation have overshadowed the importance of embracing mother during her perinatal period, fostering it as a transformative one, and activating her strengths and grappling through her weaknesses. Taking away her right to choose the birthing experience she would like disempowers a woman into thinking she doesn’t have what it takes to endure her start of motherhood. This negative experience can be further marginalizing for women of color who are at the mercy of systems not designed for their true lives. Rather than embrace the unknown of childbirth and motherhood, western society has come to understand it via “controlling ways” rather than “parallel processed ways” (Davis Floyd, 2001). Birth is not meant to be a transactional process; it is meant to transform women into being empowered mothers (anesthesia or not) empowered to care for their newborns in ways only they can. Doulas and Biological Outcomes There is significant evidence that the use of a Doula during prenatal and childbirth periods can reduce the use of obstetrical interventions, use of analgesics, and Cesarean section option. 53 Meta-analyses of randomized clinical trials of Doula or Doula-like care demonstrate reductions in the Cesarean delivery, length of labor, analgesia use, operative vaginal delivery, and 5-minute Apgar scores less than 7 among women who have continuous support during labor ( Scott, KD., Berkowitz, G., & Klaus, M. (1999); Zhang, J., Bernasko, JW., Laybovich, E, Fahs, M., & Hatch, MC. (1996). Doulas do not supplant the role of medical care providers (physician, nurse, midwife), family or partner members during labor and delivery. Her sole job is to continuously provide comfort, emotional, and physical support throughout labor and birth. This continuity of care, human presence, and social support is unique to the role of the Doula and sets her apart from any other model of support for laboring women (Gilliland A., 2002). Methods of birth are significant to consider due to their related morbidities and mortality sometimes resultant, and even more so for women of color, specifically African American women. Cesarean sections have been on the rise for decades worldwide in most industrialized nations (World Health Organization, 2015). Too many women choose cesarean birth because of fear, lack of information, and improper guidance by their care providers. Cesarean sections may cause short- as well as long-term consequences for both the mother and the child and impose further risks in future pregnancies. In 2017, the National Center for Vital Statistics reported a total rate of 32% of all births in the US were delivered by C-section, with Black women enduring the highest rate at 36% (Martins, J, et. al, National Center for Vital Statistics, 2017). As well, the rates for maternal morbidities (9% vs 2.7%) and mortality (13.3 vs 3.6 per 100,000 deaths) are approximately three times higher for mothers who have a C-section as compared to vaginal delivery (ACOG, 2014; Main, E., et al, 2012). And, in California, 37% of African American and Black women delivered by C-section (March of Dimes, 2019). A key recommendation of the ACOG Consensus report was that with continuous labor support, such as a Doula, reduced delivery interventions and C- 54 sections could result. What is evident in labor and delivery experiences now is that the experience has become more diagnostic for the system workforce, leaving a gaping hole where emotional and educational support is needed either by a family member (sometimes not available or best choice) or professional that is trained to be mother centered and focus on her mind and body during this transformation – known as a Doula. Financial Costs of Birth Financial costs of childbirth also are of great concern to the public health system. Annually, $111 billion is spent on childbirth related hospital charges and these exceed any other type of hospital care (Strauss, N., 2012). States such as Oregon, New York, Minnesota and Wisconsin have expanded access to Doula care, and studies have shown the potential to reduce childbirth related costs (Chapple, et al, 2013; Gilliland, et al, 2013; Kozhimannil, 2013; Tillman, et al, 2012). In a systematic review produced by ACOG 5 and SMFM 6 in 2014 and reaffirmed in 2019, Doulas or continuous labor support (and arguably full spectrum Doulas) are recommended to reduce costly childbirth interventions like birth augmentation, use of vacuum and forceps, and C-sections (ACOG, 2014, 2019; Kozhimannil, KB, et al, 2013, March of Dimes, accessed 2020). Natural physiological birth is the recommended model in research for those low risk medical pregnancies, and midwifery model of care delivered by midwives was associated with reduced medical intervention and increased decisional latitude during labor and birth among women with vaginal births (Sakala and Corry, 2008; Sakala and Corry, 2010, Declerq, et al, 2019 ), however, childbirth has become technocratic, impersonal and another disempowering experience for many low income mothers. Overuse and medicalization of unnecessary procedures with no evidence 5 ACOG = American College of Obstetricians and Gynecologists 6 SMFM = Society of Maternal Fetal Medicine 55 available showing their benefits has become the norm in most private and public hospitals especially (Goer, and Romano, 2012). What is unfortunate is that instead of capitalizing on the opportunity during prenatal care, childbirth and postpartum periods, the health care system continues the disempowerment low income mothers already feel in their daily lives. By not allowing for autonomy in decision making during these periods, this disconnection can resurface old traumatic unhealed wounds, and stunt the growth of self-reliance, resourcefulness and efficacy possible during these periods by way of health system workers’ supportive activities. Without this personal growth, a mother is at risk for carrying that trauma into her motherhood with her newborn, preventing healthy attachment and bonding and a foundation for a healthy start for her baby. How can one actualize a healthy difference in her offspring if she is not healing herself? The Psychology of Birth The journey through pregnancy and birth psychologically and clinically is a time for the mother to explore her strengths, fears and goals for motherhood; and addressing this with trusted professionals can assist her in this soul-searching path to having another life depend on you for everything. Pregnant women experience fears and anxiety around the labor experience, pregnancy outcome, infant care and health, and the maternal role. Endogenous catecholamines (epinephrine, norepinephrine, and dopamine) are released during times of pain, anxiety, and fear such as labor (Campbell, DA., Lake, MF., Falk, M., Backstrand, JR. (2006 Feb). The more the woman fears the pain, the more tension it produces in the muscles, and the more it results in pain once again. The way we come in to the world can be a meaningful experience. A time when our first individuation occurs from our source. Giving in to that transition can reduce a mother’s fear and worry, and allow for her core strengths to come through – maybe even parts of herself she has yet to know. Removing choices, controlling the process and eliminating support during this 56 miraculous event can damage a woman’s sense of self, or reinforce her disempowered state experienced in daily life, leaving her feeling alone in a sea of present professionals. Support from those she trusts is essential during this “sacred” period of vulnerability, responsibility, and transformation (Gaskin, 2011). Developed in collaboration with Mary Ainsworth, Bowlby’s attachment theory integrates theories and tenets from psychoanalysis and developmental psychology. Mary Ainsworth developed the empirical methodology to test some of Bowlby's ideas and also contributed the concept that the “attachment figure provides a secure base from which an infant can explore the world” (Ainsworth, M. & Bowlby, J. 1991; Ainsworth, M. et al, 1978). Within the endearing, nurturing experience exists bonding and attachment, in this case between mother and fetus and then infant. In the beginning of the bonding and attachment, the thought was that directly after birth there was a critical period where “delicately choreographed events occurred, either rooted in innate drive or emotional need.” This was when mother and baby would have the chance to bond in skin to skin through breastfeeding and cuddling which set a cascade of biological reactions that triggered expulsion of the placenta, closure of the uterus, reduction of postpartum bleeding, and facilitation of the initial flow of priceless colostrum and mother's milk. This “engagement and disengagement” during feeding and emotional response between mother and baby is now known to be “psychoneurobiological” in that early social communications and emotional experiences influence development/creation of neurological pathways, now also being studied by attachment researchers (Schore A, 2002). The development of the baby’s attachment style (and the early stages of personality) is thus thought to be a product of the baby’s “genetically encoded biological (temperamental) predisposition and the particular caregiver’s affective-relational environment experience dependence” ((Schore A, 2002))—essentially nature and nurture combined. 57 Schore et al states that the emotional development between mother and baby is the integrating link between mind and body. Directly excerpted from this article is his eloquent explanation of this psychoneurobiological relationship (Schore, 2001). “If attachment is interactive synchrony, stress is defined as an asynchrony in an interactional sequence, and, following this, a period of re-established synchrony allows for stress recovery. The mother and infant thus dyadically negotiate a stressful state transition. Infant resilience emerges from the child and parent transitioning from positive to negative and back to positive affect. In this manner, the child learns how to tolerate, regulate, and cope with negative affective states. The baby's brain, which is more than doubling its size in the first year, is not only affected by these transactions, it's growth literally requires brain-brain interaction in the context of an intimate positive affective relationship. This interactive mechanism requires older brains to engage with mental states of awareness, emotion, and interest in younger brains, and involves a coordination between the motivations of the infant and the subjective feelings of adults. These moments of imprinting, the very rapid form of learning that irreversibly stamps early experience upon the developing nervous system and mediates attachment bond formation, are described in the current neuroscience literature.” For women for which attachment is difficult or impaired by past trauma, system trust issues or other anxieties, having a professional present is imperative in a mother centered model that is based in her lifecourse. This type of professional fills a critical gap in care that sharply drops the mother from care, leaving her to fend for herself with all the same issues she had prior to her delivery, except now with a dependent newborn. Likewise, one of many Harlem Birth Right Project 7 publications, stressed the importance of social support networks for women during the perinatal period, and that culturally speaking, this was heavily relied upon by African American and Black mothers regardless of social strata (Mullings, L, et al, 2001). The Northern Manhattan Perinatal Partnership also has had much success in delivering community participatory perinatal programs that proactively address adverse birth outcomes, infant and maternal mortality in Harlem by 7 Northern Manhattan Perinatal Program: http://nmppcares.org/ 58 involving mothers as mentors to other pregnant mothers, involving Doulas/birth companions, and mothers circles that allow for mothers to gain support during pregnant and postpartum. Similarly, What is critical to observe is that social support is needed not because there is an inability to care for oneself, but an innate need to stay socially connected for survival in an ominously complex world that by structure, has divided mothers (and families) and placed emphasis on “John Henry-ing” (James, S. 2009) these naturally communal periods. Increasing economic pressures to stay afloat has put extra pressure on low income families of color (mostly) that reduce time needed to adjust to motherhood, address health and social challenges, and raise a child. Postpartum mothers would benefit highly from continuous care at home by a professional like a Doula (professional postpartum health home visitor) to assist to her needs as she adjusts, communicate relevant issues that may require intervention and clinical professional support, and bond with in deeper trusted ways unseen in the hospital delivery structure, nor as prevalent in American culture today. The Coalition for the Improvement of Maternity Services (CIMS) further supports a paradigm shift to one of at least humanistic in nature through its Mother Friendly Childbirth Initiative, where a charter guides its implementation via 10 steps to mother-friendly care. These 10 steps outline a shift of power back to mother during labor and childbirth, encourage participative maternal autonomy in decision making, honors the normalcy of birth, espouses “do no harm” first if no scientific evidence support an action, and acknowledges the responsibility of evidence based care for mother and infant care (Gaskin, 2011; Hotelling, B., 2007, Wagner, M., 2006). ACOG has also published a consensus paper that purports that continuous labor support assists in reducing the rate of C-sections (ACOG. 2014, 2019). The popular trade position for continuous labor support specialists is called a Birth Doula. Full spectrum Doulas also exist who 59 tend to a woman psychosocially while she is pregnant, during labor and delivery, and in the postpartum. The support she offers is invaluable as she is focused on providing the mother unfettered support, education and focus as she journeys through becoming a mother (for the first time or more). Doulas, given their focus on developing a positive, empowering, and supportive environment psychosocially, can assist in mediating current or prospective stressful events related to pregnancy, childbirthing, postnatal care for stress-prone women, which ultimately put them at risk for developing pre and postnatal depression and/or anxiety and adverse mother-infant bonding. Why Do the Postpartum and Interconception Periods Matter? With a different lens, pregnancy is not the only window of opportunity; equally as important is the 18 months after pregnancy at minimum for the mother, and 5 years for the child (First 5 CA, 2017, Zero to Three, 2017). Postpartum period is defined as the period after delivery up to one year, and interconception is the period between pregnancies. Taking proactive steps to be healthy physically, mentally and socially during this time is thought to increase assist with getting pregnant, pregnancy health overall, and staying pregnant (CDC, accessed 2020, March of Dimes, accessed 2020). To lower the risk of preterm births in consequent pregnancies, birth spacing (time between pregnancies) to this minimum time period of 18 months is a necessary step to adhere to for mothers, for providers to proactively manage, and the health care system to medical cover (ACOG, 2019; March of Dimes, accessed 2020) . ACOG recommends that interpregnancy care is a critical period, as well, for the continued management of the social determinant of health, mothers’ either gestationally developed or longer history of chronic diseases, including depression and anxiety (ACOG, 2019; ACOG 2018). The 4 th Trimester Project developed by University of North Carolina, Chapel Hill (UNC, Jordan Institute for Families, accessed 2020) purports that the 60 first three months after childbirth is a vulnerable period for mothers physiologically and mentally, but a time of great opportunity for care quality improvement, and a critical point of retained engagement (Tully, et al, 2017). Lu, Kotelchuck, Culhane, Hobel, Klerman and Thorp also stressed the importance of interpregnancy care as a means to improve next pregnancies and their associated birth outcomes, highlighting the importance of continuous psychosocial supports (to attend to the still present SDOH) in addition to medical care (Lu, MC, 2006). Similarly, Reva Rubin describes a paradigm for motherhood adjustment that may be helpful in describing what mothers experience postpartum. The paradigm is laid out in three phases: “Taking In, Taking Hold and Letting Go.” Each phase is indicative of a transitional arc and journey she moves through as she adjusts herself into motherhood’s role and responsibilities, and then adjusts to her newborn, and instructs nurses and paraclinical intrapartum and postpartum care workers what supports are needed by mom, and how to provide them. Mothers who deliver on Medicaid are dropped off of insurance coverage by 10 weeks postpartum, unless eligibility for other specialized, rare programs. Opposite of many other western, developed countries, the US drops mothers in a most critical time of need when many chronic conditions become worse, recovery is now being defined as a year postpartum for mothers, mental health issues are more prevalent, and newborns are completely dependent on the mother for their survival. For this reason, and to flip the script on how to reach mothers through their infants, pediatricians are more readily being integrated now into the new web of networked postpartum services, but this is not yet common, takes intricate systems changes and the will and value that mother and baby are a dyad for at least 2-3 years postpartum. Issues such as dyadic care, breastfeeding, safe sleep, reading to one’s child, nonviolent parenting and postpartum depression and/or mood management are all health issues being researched and piloted for 61 effectiveness, with early results showing strong promise (Howell, et al, 2012; Howell, et al, 2014). From a non-patriarchal perspective, the Centering Healthcare Institute 8 (designer of Centering Pregnancy™ mentioned earlier) leverages the communal nature of the postpartum period, parenting and pairs facilitated medical guidance from clinicians, like medical doctors in family medicine, pediatrics, midwifery in its sister-designed program called, Centering Parenting™ (Bloomfield, J and Rising, SS, 2013). In one study, this model was found to have a positive effect with lower income Medicaid seeking families on metrics of mother-baby bonding, increased pediatric visits for immunizations and well-baby checkups, mother-provider relational satisfaction, and the often underemphasized importance of mother-mother relational support and peer learning (Gullet, et al, 2019; Jones, K, et al, 2018; Johnston, JC, et al 2017). Continued care coordination is also becoming a strong element in perinatal and postpartum care. PRIME (Public Hospital Redesign and Incentives in Medi-Cal, funded by California’s Department of Health Care Services/DHCS) and HEDIS measures are monitoring postpartum return visits, breastfeeding continuance, chronic disease management, hemorrhage, primary C- sections, to name a few, for quality and rates; therefore, this navigation and psychosocial support is critical not only for mom and baby, but for regulatory standards (DHCS, accessed 2020; NCQA, accessed 2020). Often, though, health centers do not have the capital or reimbursement mechanism to pay for what is commonly called (although an old term) “case management”, and the system is only able to rely on auto phone calls from the hospital, the occasional social worker call (if mood disorders were mentioned during her inpatient experience), or an auto phone call or reception call to remind mom of her postpartum appointment. The health care system has forgotten that most mothers (33% approximately) are recovering from a C-section (considered major surgery), very 8 Centering Healthcare Institute: https://www.centeringhealthcare.org/ 62 likely experiencing a “let down” of hormones causing postpartum blues, adjusting to zero sleep and continued housework (depending on her family and friend support network), or gearing up to return to work (low wage jobs often require a woman back to work after 6 weeks of paid maternity leave or they will lose their job, and low income mothers suffer tremendously physically, psychologically, emotionally (bonding and attachment) and relationally with this undue economic pressure. The US is one of the only countries that does not cover paid maternity leave for at least 3- 6 months postpartum, with many western developed countries covering at least a year or more, e.g. Canada, Germany, England, France, Spain. With no emphasis on the building of a family, newborns are left to be raised by other mothers, like nannies/caregivers/grandparents/aunts, rather than with whom their psychoneurobiological attachment is greatest – mom. With this lack of economic and value driven support nationally, it is hugely imperative that health care systems include in clinic AND home based/community based Doulas (National Health Law Program, Chen, A., et al, 2019; Strauss, N, 2012) and postpartum Care Coordinators (ACOG, 2018; Verbiest, S, et al, 2018; Fahey, JO and Shenassa, E, 2013; JJ Way) and extend their FORMAL partnerships beyond their brick walls to community based networks to continue the good work started in the prenatal (hopefully) and further enhance the support to include the basics aforementioned (on physical, mental and parenting), but also what SHE defines as priority in her life at that time. A mother’s community is her home and where she spends 90% of her time; so, understanding her neighborhood, how to leveraged it and where to fill in the gaps is not only logical, but the best practice put forth by multiple disciplines – social work, psychiatry, psychology, public health, community partnered participatory methodology, home visiting and early learning advocates. Researchers and providers alike do not know what they don’t know – in 63 that, until their mother patient becomes postpartum, they will not know what rises up to most important for her, and meeting her there will show mom that she comes first in their care planning, not the medical agenda. In this role, all health and community practitioners have then the responsibility to take the postpartum journey with her, and in doing so, can activate a tiered level of service model whereby this sort of paraclinical “maternal buddied 9 ” support serves as mom’s anchor for information, education, psychosocial resources, mood assessment and mediation, breastfeeding, motherhood transitions, and connections to specialized care, if needed, like continued chronic disease management (a strong predictor of preterm birth and low birthweight, and even higher likelihood of maternal mortality). Rays of light in this field are surfacing (finally) in New York, Washington, Oregon, Michigan who are funding Doula pilot programs as calls to action to address the egregious rates of maternal mortality in African American and Black mothers which number 3-4x their White counterparts. Until interconception care financing can be passed through health insurance companies and federal and state regulation, private and public/government grantors must fund Doulas, Home visitors and Care Coordinators to fill this ludicrous gap in care for mothers, and government health care systems (like departments of health and federally qualified health care centers) must make the paradigm shift to mother centered care that is racially tailored, grounded in community based networks and shared decision making, and focused on relationships built on genuine empathy and trust. 9 Moini, Moraya, MPH. 2005-7. Unpublished. Terminology used in Mother Friendly Care consulting and doctoral proposal submitted to the London School of Hygiene and Tropical Medicine/University of London, Royal Holloway. 64 The Significance of Maternal and Infant Health Phases: Summary Mothers are the bellwether of a society. Adopting a minimum of a 2-generation model of care that incorporates and leverages the protective factors and strengths of mother and father alike provide a rich foundation on which to support healthy physical, mental, behavioral and systemic change outcomes. Lifting mother and father up economically by investing in a reprioritization of values at the federal and state levels towards family strengthening via periantal and interconceptional health programming, gives families a chance to survive and thrive. Assumption that families of color take advantage of the system is a selfish perspective of such a complex wicked set of systemic issues that predispose families to become low income and at the mercy of subsidies and government assistance. Government and private systems that step down from a pulpit of superiority, competition, and individualism to recognize and reflect within will see that all Americans are essential to our economic and societal fabric, and thus, essential to humbly cherish at every level of socioeconomic status. Confident societies realize this necessary bell curve and strive to spread out wealth among diverse racial and ethnic populations. Creating these societies begins with system redesign and investing in mothers and families, especially women of color and those with the most adverse maternal and infant health outcomes. Models and Strategies Aiming to Improve Maternal and Infant Outcomes Health care systems of old technocratic, turn of the 20 th century hold characteristics that are top-down, White tower, not inclusive and punishing and blaming. For those of color, this system is even harder to navigate for reasons including, levels of health literacy, middle/upper class insurance designs and expectations, and paternalistic versus communitarian ways of communicating. Plainly said, the system blames the victim and is designed for the upper White socioeconomic class. For 30 plus years and now to respond to ACA, community based perinatal 65 health programs have been striving to put the mother (and baby) at the center of care, proactively include and leverage her community to support her perinatal health, and address her holistically as means to combat a system that was not designed to serve the majority of the American population. Although other models such as Nurse Family Partnership and other Home Visiting programs have yielded varied healthy outcomes, some physical, and more psychosocial, none have brought all disciplines together (medical, mental, social) in clinic and home, and several have been shown to be more costly in operation. And, helpful and excellent sources of assistance, the CPSP program, NFP and even the Black Infant Health programs in California have not yielded strong effects on changing the rates of adverse birth outcomes. Explanations for these disparities can no long stay on the individual level; macro level systemic issues need to be traced for biases that contribute to lifelong discrimination and prevention of advancement and equal treatment. Older paradigms of care, such as a midwifery and Doulas, and newer models, such as Centering Pregnancy (group prenatal care) and maternal/pregnancy medical homes are emerging – all with the same virtues (but in varying degrees) in mind of shifting power back to the mother as the driver of her own body, mind and care – in other words, “autonomy.” These evidence-based models all commit to creating more autonomous or shared decision making in care, and being less technocratic and more humanistic in approach. What has been lost for many mothers is a medical service provider that really knows them, embraces their multiple issues in a personalized way, and commits to betterment with them throughout pregnancy, during labor and birth and into their first years of motherhood. From a health disparities lens, the postpartum and interconception periods hold much importance for under-resourced mothers of color. African American mothers have internalized the abandonment from health care service systems, and as a result, carried the epidemiologic 66 burden of disease. As emphasis to combat these issues, community-based efforts have stepped up to serve them in innovative ways, some aforementioned. Briefly and first, it is important to highlight the role of the Granny Midwife to begin to comprehend why racially tailored care is historically relevant but also needed. Black Granny midwives were the only way Black mothers could birth in the times of slavery and Jim Crow South (American US) because medical institutions did not allow Blacks in them. Black Granny midwives were part of the core fabric of the Black ‘enslaved’ community, and were, “….much more than {about} catching babies; they were psychologists, dietitians, loan officers, sex therapist, prayer partners, marriage counselors and friends and sometimes relatives to the women that they served” (Brown & Toussaint, 1997; Monroe, S. accessed 2020; Kitzinger, S., 2001; Taylor, J., et al, 2019; Zoila Perez, M. 2015). Black women were often the source for breastfeeding their White master’s slaves, as well. Black women and men became the subjects of research without their consent when medical research became more prominent during the scientific revolution at the turn of the century. As birth was stolen from mothers and women in general, Black mothers were even more ostracized from what became a ‘controllable’ event. Women in general were kept out of delivery rooms while White women delivered their babies to male physicians. As well, Granny midwives became the scapegoats for ‘witchcraft’ as it related to birth in the South, as birth became more medicalized and infant and maternal mortality began to rise (Taylor, J, et al, Center for American Progress, 2019). New licensure was required by any midwife because medicine by men became the only method of obstetrics. Prohibitive costs to gain licensure, unpopularized Midwifery programs that held a demographic of mostly White women, and a non-racially focused curriculum in these Midwifery schools and later, Doula programs, steered an originator of these mother centered practices away from their own model. However, a resurgence of mobilization to take back birth 67 by the African American mother advocacy groups have been pushing funders and legislation to change its systems to accommodate more models of Midwifery care and now, Community Based Doula programs. As stated, advances in medicine are not the problem; it is how and when and where they are used and for whom they are used that is the problem. Another two examples of racially celebrative and tailored, mother centered care models are Mamatoto Village and JJ Way who have recaptured cultural historical matriarchal roles, such as the Granny Midwife, to serve women in more racially minded, accessible, unbiased and soul- connecting ways (Taylor, J, et al, Center for American Progress, 2019). Both of projects center directly on the mother, not the system – creating a deference to a pregnant and postpartum mother as exalted during this time of life generation. Mamatoto Village 10 , a nonprofit community-based organization based in Washington DC, provides full spectrum mother centered support to women of color and showed promising results of 89% breastfeeding, 92% postpartum return visit rate, and zero maternal and infant losses (Taylor, J, et al, Center for American Progress, 2019). Jennie Joseph in Florida created a community-based mother centered model called, the JJ Way™ 11 , which in 2017 showed lower preterm birth and low birthweight rates than the general population in Florida’s Orange County and state at-large. To account for higher medically at risk mothers, JJ Way midwives partner legally with a physician and hospital to ensure oversight of safe practices and birth outcomes, as well as, postpartum follow up care (Joseph, J., JJ Way, accessed 2020). With racial discrimination endemic, the case for trauma informed care or a resiliency-based framework to administering health services is paramount in the current era of health care. Social determinants of health have been recognized in the past several decades as strong contributors to adverse health outcomes. These determinants include issues with lack of affordable housing, 10 Mamatoto Village: www.mamatotovillage.org 11 JJ Way: https://commonsensechildbirth.org/jjway 68 mental health illnesses, fragmented social networks (low social support), lack of access to quality healthful foods and nutrition, substance use/abuse dependency, exposure to community and domestic violence and security, and lack of economic advancement opportunities and adequate public education, to name a few. For those struggling with racial discrimination, these social ills seriously compound the load of stress related to managing one’s quality of life, leading to a “weathering” decline of health status (Geronimus, A, 1992). Chronic maternal stress and depression can result from this weathering, setting off an allostatic load and inflammatory responses in her body which put her fetus at risk for preterm birth and predisposition of disease later (Barker hypothesis) (Lu and Halfon, 2003; Kramer, et al, 2011). Health services can no longer just attend to medical diagnoses by addressing just the physical phenotypes of disease, but now must integrate and address the adversities related to those physical problems with a multilevel, multidisciplinary approach that goes beyond the walls of the health care system and involves community organizations and mothers voices (Beck, et al, 2020). Comprehensive psychosocial assessments have been used for several decades by programs like the Black Infant Health program, Comprehensive Perinatal Services Program, PRAMS, Healthy Start Initiative, MICHEV funded programs in home visiting, and other newer maternity models of care. Aiming to account for the social determinants of health, these assessments, if administered in a trauma informed or sensitive manner, can reveal stressors in mothers’ lives that may adversely impact her pregnancy. One scale in particular getting more attention in health care assessments is the ACE, or Adverse Childhood Experiences scale. Through its validated design it addresses a person’s lifecourse experiences that may be contributing to behaviors that challenge being healthy. Although when to ask it in the course of care is highly debated (e.g. later, when relationships are built with the patient vs. at the start when care begins) and pairing it with an 69 assessment of an individual’s protective factors, it is a tool that is being widely integrated into assessment infrastructures. The overall attempt for health care systems has been to reveal the traumas that may be impacting a person’s behaviors; however, again, revealing more challenges that a mother faces is not going to make her resilient or better able to cope in the immediate term. It is asking the system to reflect and evolve to be less discriminatory, more tailored, more relationship based and communally and community centered in its service delivery, and overall, system and society helping to change the narrative for those least fortunate (African Americans and Native Americans). Health care systems need to do their part to be trusted by groups that have been left to fend for themselves. And, they need to breakaway from a dominant culture of caring only for oneself rather than all. Within this construct of addressing adversities is the flip side – resilience. Scholars and various discipline practitioners have touted that better resilience can be achieved by building the capacity of individuals (especially African American women and children) to self-regulate, having supportive structures holding them (schools, clinicians, family, faith), removing oppressive systems that keep individuals (children too) stunted in chronically stressful environments or status (Sumbul, Spellen and McLemore, 2020). Harvard’s Center for the Developing Child have invested heavily on investigating building resilience in children to support a stronger generation upcoming. They provide several similar definitions of resilience by different disciplines, but, thematically describe it as, “a person’s ability to adapt successfully to acute stress, trauma, or more chronic forms of adversity” (Harvard, Center for the Developing Child, 2015). Similar to the aforementioned narrative on organizational resilience, it can be considered a process, capacity or outcome; however, commonly, in health services in working with individuals (and children), mitigating external factors that chronically stress the biological system and building the capacity 70 within the system to regulate itself are the goals. But, for certain racial groups, like African Americans and Blacks, there is little to no recovery period for these biological processes, and thus a constant state of high alert and stress result (Harvard, Center for the Developing Child, 2015; Dunkel Schetter, 2011; Ramey, SL, et al, 2014; Melon, LC, et al, 2018; Cohen, S., et al, 2007; Taylor, J, et al, 2019; McEwan, B., 1998). Further, added stress during a provider visit can negatively affect a mother’s desire to continue accessing prenatal or postnatal care. Trusting relationships with providers, access to social support, and respectful staff and providers were all mentioned as highly important in focus groups among African American pregnant women (Mazul, MC, et al, 2017). Therefore, assessment of stress, traumas and additive adversities are inherently personal, and require trust with anyone who aims to stand beside her. Social justice and science comes together when epidemiological research can be translated into community concepts for marginalized groups in a way that is empowering, not damning or doom and gloom. Rather, once contextualized, the affected group can choose to mitigate their own behaviors to make change, and/or highlight the systems’ inequities to mobilize against structural racism and oppression in a systematic way Summary The charge to large complex bureaucracies is to step away from the impersonal aggregated and non-humanistic design that holds up the system, and focus on the individual person in front of them who, by nature, requires personal attention, relationship based on trust and equality, and genuine empathy to achieve any dent in perinatal health outcomes’ disparities (i.e. infant and maternal mortality, preterm birth, low birthweight, maternal depressional and suicide and associated chronic disease predictors). 71 Importance of Program Evaluation Supporting a learning organization is one objective important in the arc of a department and its programs. For a program expanding its scope of practice, learning more about its assets and weak points is critical to moving forward. A few methods can assist with this in prior to beginning and in real time, including a logic model or driver diagram, and continuous quality improvement. Using a logic model or driver diagram can be useful in assisting with the design of a program, as well as, a good reference when retrospectively examining what was efficient and effective about the program. Additionally, this exercise sharpens the focus on what are SMART, or specific, measurable, achievable, realistic and time bound goals and objectives (Doran, GT, 1981; Drucker, P., 1954, 1955, 2007). Likewise, taking part in continuous quality improvement can improve intermediate measures of success by first, defining a dashboard of metrics important to end outcomes, and then pairing them with quality improvement methods. One evidence based model of quality improvement is called the Model for Improvement and within it, it contains a method used frequently in the health care setting called the “Breakthrough Series” (IHI, 2003) developed by the Institute for Healthcare Improvement to reduce costs, using non-evidence-based methods, injuries to patients, and poor service. This method is an activity done collaboratively among all parties associated with the desired outcome and needed changes. Last, incorporating the voices of the end user is no longer an optional task in program planning, especially in health care; it is a ‘must have.’ Not investing in understanding one’s population in greater detail can lead to being in less demand, because consumers will speak with their feet – they will go somewhere where what they value highest is offered in a way that is respectful and tailored. 72 Frameworks for Individual and Organizational Change I. Organizational Planning Theory and Frameworks Brief History In many disciplines, participation and collaborative decision making are used to garner support and buy in for changes desired in planning and policy. Moving from theory to practice tends to be a challenge for some as they try to apply what rational science has posited versus what is likely to be utilized in practice. Whether organizational or at the community resident level, defining what is important is critical to the change’s sustainability. To traditional leaders and decision makers, a more methodical, logical approach using only validated and published evidence seems like the “right” way to do it; but to those who experience the changes or demands, taking this autocratic approach is oppressive. To those closest to the issues, certain more ancillary factors, such as fixing potholes and having access to quality care, is more important than solving ethereal problems very removed from them. The challenge is balancing agendas of both sides, establishing individual and mutual “wins”, building a genuine, trusting relationship and allowing the time for organic deliberation are essential to witnessing actual change. Fainstein discusses the challenge of translating theory into practice in “Planning Theory and the City,” focusing on the danger of using myopic definitions of planning as the basis of planning with communities. Isolation of theory from practice is painted as a barrier to supporting long lasting improvements mutually beneficial to institutions and those affected. She talks about changing the perspective to ask why planning has not been at the urban level, rather than the way it is now and has been historically used, removed and exclusive to high level, elite decision makers (Fainstein, 2005). With shifting the “control” of planning to include participants at different levels in different sectors, planning could see a potentially different outcome because the inputs (diversity 73 of actors) were a more representative sample of ideas. Fainstein goes on to include not completely blaming traditional planners as solely responsible for community’s “wicked” outcomes, but honors that political forces needs to be factored into the equation as “wicked” external forces/threats to how a planning effort resulted (Fainstein, 2005, Box, et. al, 2001). To get beyond the rational method of decision making, accounting for the barriers to performing representative deliberation for both sides must be considered. For both traditional decision makers and community participants alike, time, resources and intentions pose as barriers (McCaffrey, 1995, Carp, 2004). In the past and much so currently, centralization of control of planning and policy has dominated, leaving communities out of the circle of influence. McCaffrey and Carp write about the inherently fallible notion that without more decentralized control, truly participative systems or planning will ultimately still fail because of its inherently lack of change from the “top to the bottom”(McCaffrey, 1995, Carp, 2004). In addition, McCaffrey writes about the challenges that undermine participative systems when they perform collective planning, and includes issues such as: “dispositions against cooperating with prior adversaries, the costs of collaboration in complex social and political systems, the difficulties of engaging in deep conflicts and the concrete leadership incentive favoring control that develop in this context,” (McCaffrey, 1995). He argues that having “perspective” when planning, and likens it to Max Weber’s point of view on “ambivalence” where liabilities and advantages of bureaucracy need to be accounted for, and were linked and inseparable (McCaffrey, 1995). Box, et. al further supports honoring the challenges for both sides by describing one way of viewing substantive democracy as one that offers “the choice” to “take part in governing themselves with a minimum of interference or resistance” from experts, economic, political or administrative, without “being required to assume…..a universal set of constraints” like neoclassist, normative 74 decision making styles, and one that advocates for free, informed knowledge sharing. In that light, moving away from styles that hoard decision making to a few and redirects power back to the many will set the stage for change at various levels – provided that is truly what the elite corporate or governmental forces really want. The disadvantages of centralized control characterized by restriction of information, inapplicability to its users, can continue to oppress end users, exacerbating a feeling of victimization, learned helplessness, survivalism (as opposed to higher actualization of self and society), hopelessness and low self-efficacy. These traits at both the individual and societal levels is dangerous, as it continues to support so called theories from rational economists that “they didn’t want it anyway, and if they did, why didn’t they go get it?” Seeing citizens as consumers only, not as resident in a participative, socially conscious-centered society continues the vicious cycle of dependence on rational economics to prove how people and organizations should operate in a “highly individualized, technologically dynamic society” based on money and profit as defining worth (Box, et.al, 2001). However, given that individuals of communities do not operate in a vacuum and are affected by market forces and environment, reaching for more becomes a harder task (than to more privileged) and change happens at more of an incremental pace over many generations, instead of within one generation. Even at the organizational level, lack of seeking out representation in decision making can make employees feel resentful, unacknowledged and replaceable; making it more apparent that “rowing” instead of “steering” is an important value and method to approaching change at any level. A critical part of change includes not only changing to participative decision making and planning, but to also train managers to value and exercise this model. Inherently, this means that investing in skills training in management must also be backed by senior leaders within the 75 organization, so that smooth implementation is achieved, and the changed method is accepted as both a value of the organization and authentic (Box, et al, 2001). This is described in, “New Public Management and Substantive Democracy,” further as problems still remaining because the public sector stills fashions itself after private business, which is counteractive to a more consciously collective operating environment (Box, et al, 2001). This paper goes on to explain that imposing a market model within managed health care is discontinuous with shifting the power to change back to the provider and down to the patient (consumer….once again, labeled in economic terms) as it looks at all parts of the whole as related to the bottom line, not human practitioners working with human patients. But, in a market model, whether health care, education, or social services, I cannot help but think, do they really want genuine participation, as control of masses is easier when contained to a few rather than the many? For example keeping people sick keeps people in business. However, with new policy acts such as the Affordable Care Act (ACA), care quality, patient-centeredness and easy navigation will be valued higher than the dollar; moving from a boat steered by a few, to a boat rowed by many. Denhardt and Denhardt describe this perfectly in their paper, “The New Public Service: Serving Rather than Steering,” in their statement, “are we forgetting who owns the boat?” (Denhardt, et al, 2000). They describe the seven components of New Public Service (instead of Management as the old paradigm) to include: 1) Serving rather than steering (facilitating improvement rather than imposing, e.g. corporations a player not the driver); 2) Public interest as the aim, not the by-product (supporting shared vision, interests and responsibility not autocratic decisions benefitting the few); 3) Thinking strategically, and acting democratically (upholding collective action not disingenuous collaboration); 4) Serving citizens, not customers (seeing people as participants in a society, not merely consumers to be bought and competed for); 5) 76 Accountability isn’t simple (ensuring public servants seek information from all sectors and report back using an iterative process to get to decisions); 6) Valuing people not just productivity (valuing shared leadership based on mutual respect by public organizations and their networks, finding new metrics to evaluate performance); and 7) Valuing citizenship and public service above entrepreneurship (working fairly as a public servant recognizing that public money is not their own, but the public’s) (Denhardt, et al, 2000). These tenets shift the paradigm from “managing” people to “working with” people to achieve goals – leveling the playing field away from a hierarchical, fear-based, top-down, solely profit driven way of setting up infrastructures and operationalizing plans. Based on this and that America is a democratic nation, it is important to still value financial and operational effectiveness and efficiencies, but planning and policy should expand its realm to include equality and fair representation, community residents and neighborhoods as principles by which to make decisions – or in all, be civic engagement minded. In close, by establishing from the start the values of patience, cultural competency, sustainable change and shared ownership, achieving substantive change is possible. Cultural Competency in Planning Cultural beliefs and practices have a large influence as to how people of color/ethnicity, e.g. Latinos, receive, process and act on health messages. The degree of assimilation and acculturation for immigrants can also be a contributing factor to how one approaches health and health care. Sabogal et al. have defined acculturation, as the process of cultural exchange by which immigrants modify their attitudes, cultural norms, and behaviors as a result of the interaction with different culture. These variables play a key role in determining traditional gender roles (Sabogal et al., 1995). As a result, immigrants and non-White ethnicities face dominant culture norms unlike 77 their own, and thus may exhibit difficulties in interpreting, accessing, navigating and behaving- tailored to meet these cultural norms and mores. For many, embarrassment/shame, concerns about privacy, respect (respect for elders and highly educated), and fatalismo (belief in religion/God as all-knowing) may present as barriers to how they interpret and access health knowledge (health literacy), think/feel about health issues (attitudes), and act on prevention and disease (behaviors). Recent immigrant families, the uninsured and low income population face a large palate of issues related to accessing and navigating health care. Barriers to accessing, navigating and utilizing care are many to immigrants, underserved/low income and uninsured. Some include the lack of: money, transportation, child care, social support and language literacy. Lack of health insurance has been identified as the single most important barrier to health care services in the United States (LA Health, 2000). Those families that are new to this country may have different exposures regarding health care prior to arriving in this country. Two different cultures are “muddling through” (Rainey, 1991) as one tries to make the most of their chance in the “land of opportunity”, which makes health behavior change challenging. Their desire to assimilate and acculturate may override their own culture's practices leading them to make different choices than what is accepted in their native culture. And, lack of access to care in their home country translates to how to access and navigate a fragmented, non-patient-centered model of care here in America. In general, recent immigrants, the uninsured and low income population treat care more episodically, not preventively; and go to any location of care that will treat them, not one patient medical/wellness home. America’s poor system of reimbursement, referrals and electronic patient data (until recently with health IT) does not support efficient or effective medical planning, patient empowerment and wellness. 78 Culture plays a large role in a person’s health. If a system nor organization does not integrate cultural competency into its planning, its design and implementation will suffer tremendously, and continue to leave people in the dark, “benched” and feeling disempowered – potentially furthering learned helplessness on societal and individual levels (preserving an external locus of control, and low self-efficacy). Organizational Readiness to Change and Resilience Organizational readiness is a precursor to organizational change and must be considered if sustainable change is desired. With the many disruptions in economics, regulations and aimed improvements for health care organizations, taking stock of an organization’s capacities and resiliencies assists an organization in assessing if and how it will launch systems change. Lewin described a three-stage model of “unfreezing”, “changing” and then “refreezing 12 ” again to foment change within an organization (Lewin, 1951, Nursing Theory.org, accessed 2020). This model respectively starts with inciting the differences between one state of being to an improved other, 12 “The Change Theory has three major concepts: driving forces, restraining forces, and equilibrium. Driving forces are those that push in a direction that causes change to occur. They facilitate change because they push the patient in a desired direction. They cause a shift in the equilibrium towards change. Restraining forces are those forces that counter the driving forces. They hinder change because they push the patient in the opposite direction. They cause a shift in the equilibrium that opposes change. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered by changes that occur between the driving and restraining forces. There are three stages in this theory: unfreezing, change, and refreezing. Unfreezing is the process which involves finding a method of making it possible for people to let go of an old pattern that was somehow counterproductive. It is necessary to overcome the strains of individual resistance and group conformity. There are three methods that can lead to the achievement of unfreezing. The first is to increase the driving forces that direct behavior away from the existing situation or status quo. Second, decrease the restraining forces that negatively affect the movement from the existing equilibrium. Thirdly, finding a combination of the first two methods. The change stage, which is also called “moving to a new level” or “movement,” involves a process of change in thoughts, feeling, behavior, or all three, that is in some way more liberating or more productive. The refreezing stage is establishing the change as the new habit, so that it now becomes the “standard operating procedure.” Without this final stage, it can be easy for the patient to go back to old habits.”] – Nursing Theory.org 79 building the will to change from the status quo, and then cultivating the “self” efficacy to make the change with confidence. Similar to Albert Bandura’s self-efficacy theory, it displays that the organizational or system contains many parts and people within it that require the comfort and confidence to change (self-efficacy) (Bandura, A. 1977). Weiner suggests that changes in work flow, staffing, decision making, communication and reward systems for staff need to occur simultaneously because as any system, its pieces are interwoven and interdependent on one another; thus, working on change requires valuing the system as an ecosystem needing a collaborative, multidisciplinary and cohesive approach to change and improved resilience (Weiner, 2009). Kotter is another change management theorist and developed an 8 step process. These eight steps include: (Kotter, J., accessed 2020) 1. Establish a sense of urgency (for change) 2. Create the guiding coalition 3. Establish a vision and strategy 4. Enlist a volunteer army 5. Empower (or enable) broad-based action 6. Create short-term wins 7. Sustain acceleration 8. Anchor new approaches in culture Organizational readiness to change follows a “multi-level construct” according to Weiner that is defined as, “…an organization’s members’ shared resolve to pursue the courses of action involved in change implementation” (Weiner, 2009). Collective action is prioritized in this change as, within an ecosystem, all must be on board to agree to change, muddle through the changes, and sustain the changes. Many times, changes are made in organizations without the consent or consensus of its members, and resentment and confusion foment and even end up breaking down the desired change. Exemplifying the will to change is Herschovitz and Meyer’s observation that members within an organization either change because they “want to”, “have to” or “ought to” – 80 accenting that “wanting” to change is key to sustainable, supported change (Herschovitz and Meyer, 2002). Bandura also supports this model that to be ready or motivated for change, one must understand why the change is important, perhaps understand and agree that the benefit for one or all outweigh the risks, and see and learn how to execute the change with confidence. Gist and Mitchell explain readiness for change as dependent on resource availability, situational factors and task demands, and, as such, reliant on the “cognitive appraisal” of these aspects (Gist and Mitchell). Resiliency as an outcome is most set in the field of psychology whereby it applies the ability for an individual to recover from adversity. Similarly, this concept is used in business and organizational theory to describe what aspects it needs to be resilient, however, definitions and how resilience has been applied remains varied, especially in nonprofits (Duchek, 2019; Witmer and Mellinger, 2015). Depending on the environment one is examining, the metrics may differ some, but, similar parallels in assessments, mitigation and adaptation can be seen. A newer concept in organizational theory, resilience has not been studied much empirically nor do scholars agree on a model (Linnenlueke, et al, 2017). However, many offer critical drivers and methods of success in achieving resilience (Duchek, 2019). Some business literature defines resilience as the organization’s ability to predict risks, adapt quickly and intelligently, diversify its financials, leverage its human resources, manage its information, and utilize its capital toward multiple safe and innovative resources (Harvard Business Review, accessed 2020) It relies heavily on its leadership being resilient by both being consistent in action and messaging, and nimble by leveraging its human capital towards problem solving. Put together, resilience has been described as the ability to bounce back or recover from adversity and in some cases, predict and adapt readily to that adversity coming out stronger (Horne 81 and Orr, 1998; Lengnick-Hall, et al, 2011; Madni and Jackson, 2009; Duchek, 2019). Valikangas & Romme also advance this definition from being thought of in the past as ‘passive’ (recovering back to the same state after disruption) to being ‘actively resilient’, whereby, “active resilience or strategic resilience [is the] capability to convert threats quickly into opportunities then identify a unique opportunity and act effectively as they compete (Valikangas & Romme, 2012). Further, Duchek purports that “anticipating, coping, and adapting” are the three stages of resilience that organizations experience to become more resilient (Duchek, S. 2019). This model, seen in Figure 2.1, displays these stages and their underlying factors. 82 Figure 2.1 Organizational Resilience (Duckek, 2019) As seen here, these stage of change mirror much the health behavior theoretical literature on individual level behavior change, for example with the Transtheoretical Model (Stages of Change Model). What is helpful in this above displayed model is the emphasis on “reflection and learning” during the “Adaptation” phase. With increased power and responsibility of its leadership and human resources, this continued cycle of observing and identifying the change needed, accepting the change through cognitive and collective thinking processes, and reflecting on and learning of new methods to adapt, takes place. Without active reflection regularly on a systems level, anticipating disruptions and dealing with them when they do happen becomes increasingly difficult to unearth, let alone address. 83 As well, business consultants in America, like Accenture, PWC and Deloitte, have moved to investing themselves in and consulting financial institutions on organizational resilience, not just financial resilience. This is due to the changing influence of technology safety (e.g. cyberattacks), the rise of importance of human capital (e.g. workforce capacity and satisfaction), intraconnected people with processes, organizational interconnectedness and dependency, Although organizational resiliency requires agility in change management, ensuring that this attribute is balanced with measured processes that encourage collaborative input and information diversity is key. The human resources within that operate these processes are the organization’s best assets to preserve, protect and prioritize operational and organizational resilience. For example, Accenture states that organizational/enterprise and operational resilience is a journey of continuous improvement that requires administrative resources and a value proposition created and owed by its human capital (Accenture, 2019). Regulatory bodies, like the Bank of England, are vigilantly evaluating the solvency of profit and nonprofit socially responsible investments alike for operational resiliency (Australian Prudential Regulation Authority; 2019; Bank of England, 2018). Minimizing these systemic risks and planning for ‘disaster recovery’, they state, provide crucial stability to an organizational financial resiliency, which for healthcare nonprofits alike is important along with its ability to adequately and equitably serve its population. Knowing what will be prioritized by whom, at what point, assists the organization in maintaining its mission, vision and values (MVV) in times of crisis. The argument again supports that resiliency is not just an outcome anymore, but constitutes the processes that develop the infrastructural strength to reach it as an outcome, too (i.e. the parts must “resilient” so that the whole can be “resilient”). It is an upstream approach to security, which is reflective of changing times akin to ‘disease management’ vs. ‘prevention.’ As such, drafting a sustainability plan that 84 includes the elements of organizational resiliency is a next level step nonprofits can make to remain solvent and focused on its MVVs. Decentralization of operations and disaggregated decision making often assist with rapid responses needed in a system overload or shortage or adverse impact, therefore, training and capacity building of those decentralized operations need cultivated leaders who are capable of nimbly modeling and executing the “float” between collaborative governance (or “deliberative democracy”) and fidelity to model – able to “adjust the spine” when needed (Weeks, 2000). Similarly, RAND researchers recommend civil organizations should approach building resiliency in organizations by ensuring 1) impact avoidance (organization that cannot withstand failure, error, e.g. surgery, nuclear power plants, organization that needs to prioritize performance over profitability) , 2) adaptation and flexibility, and 3) recovery and restoration. Within these approaches, common themes from this report’s review of the literature included: i) encouraging conscious information sharing and MVV (mission, vision, values) awareness, ii) supporting a non-punitive learning environment that actively learns from errors and claims the disruption as useful iii) clear reporting structures that disaggregate and decompress issues at their locality rather than waiting for it to metastasize iv) accurate risk assessment methods that predict issues as well as examine common elements contributing to risk v) simulations of risk performed to run through issues, test fidelity to models, and objectively think through operations that reflect key components of the value proposition of the organization The full range of risks listed are not comprehensive, but can offer a way to assess the flexibility needed to remain strong during maintenance or growth. Training and technical assistance can assist with this assessment and build the capacity manage change, and ask the challenging questions of why, when and how to make necessary changes to remain current and tailored in a 85 journey of change. And, last, as an organization makes the changes it desires to be precise in its delivery of services, reminding itself of what it values will always offer a ‘true north’ in that review as the organization governs itself with collaborative intent. Arguably, put together, these profit and nonprofit models thematically represent a fluidity around a “spine” framework, which I depict here visually in Figure 2.2: Figure 2.2. Building Organizational Strength Last, as nonprofits aim for higher quality services to meet the needs of its most vulnerable populations, strategies for sustainability and strength stay high on organizational leaders’ minds. The California Endowment offers strategies to achieve this resiliency in a 2008 report to fight asthma. It puts forward that systems change is multifactorial and multilevel, as the citations mentioned above. In these strategies, collaboration or knowledge transfers through learning collaboratives (Conway and Clancy, 2009) is required for a comprehensive framework and Develop and commit to core values & value proposition Invest in human capital/resources Manage risks, connect to relevancy Balance decentralization with congruent systems, infrastructure, decision making, mission, vision, values (MVV) Reserve conscious/allow for operational redundancies Focus on adapting to changes that guide to 'true north' MVVs using methods of collaborative governance 86 centered on the population it is serving. It does not put the system at its core. This more humanistic, ecological approach has been adopted as the way to both organizational and individual level strength. Not doing so will yield results that continue to promote disparities in health, and phase out organizations who don’t meet the changing expectations of its population to be more user friendly, authentically concerned for them, and mindful of the barriers they face in improving their health status. As a guide, the report lists the following as methods and concepts to ponder when performing planning and implementation of systems change: 1) Design synergistic system to align values, activities and relationship across multiple levels of a system. Use a model with a reinforcing message. 2) Develop and encourage collaborative planning and consensus building based in data to examine assumptions and action steps for change (also recommended by Conway and Clancy, 2009). 3) Cultivate leaders, advocates and champions for change. They are the organization’s ambassadors for change. 4) Employ communication strategies to enhance capacity and leadership development among community members of the system one is aiming to change. In an organization this is its workforce. 5) Design change efforts that are sensitive to and congruent with community cultural, contextual and environmental factors. Managing the risk of an organization requires an understanding of the population it is aiming to serve, but more than understanding is how it decided together how to tailor its efforts bravely and innovatively to match community needs, strengths and external threats it faces. 6) Institute and reinforce appropriate feedback loops to augment or rectify plans and actions and to encourage dynamic analysis, learning and change. 7) Assess unanticipated positive and negative consequences that affect the activities and interrelationships codependent on one another. These are just a few mentioned points in the report that are salient to the issue of organizational change. 87 Readiness and resilience are mentioned in this dissertation as both a motivator for change and a state of which to aspire for health care systems looking to shift paradigms. Like LACDHS, systems and organizations seeking to improve itself to meet the needs of its service population better, they must consider its predisposing, enabling and reinforcing factors by engaging in adequate planning (Green, L, 1974; Green and Kreuter, 1999). An organization’s collective knowledge, attitudes and behaviors (culture) predispose its ability to change. It is how an organization approaches the notion of change, and indicates where it is starting on that arc of change. Not assessing these can be detrimental to progress and buy in of the human resources collaboratively making the case for change. As well, understanding what the organization has working for and against its change is critical. Doing this with all parties involved, although time intensive, helps paint the landscape of what the change will run up against on the way to the desired change state. Aspects such as lack of funding for staff for the particular change, a champion for change, a coherent design, staff positivity, team-based worldview, and adequate timing in operations are all enabling factors to be considering highly before launching change. Last, reinforcing factors can including people, places or things that support (positively or negatively) the desired change. Thinking through, whether quickly or over time, these three groups of factors can assist an organization and its human resources to build the relationships among one another to respect and endure change, and, the, continue to be nimble. As noted in the above profit and nonprofit examples of creating and maintaining organizational readiness and resilience, it requires a “risk intelligent” sustainability plan that is inclusively crafted, representative of its multidisciplinary parts, clearly tethered to a “spine” of more constant elements and attributes, fluid and agile to respond to changes needed, and rooted in its decided upon core values and value proposition. 88 II. Individual Change Theories/Models Organizational change theory can follow an arc of progress that can be compared to behavior change theories such as Maslow’s Hierarchy of Needs and the Transtheoretical Model. Both theories speak specifically to the readiness to change (motivation), and thus, the efficacy (or comfort and confidence) the entity feels or objectively reaches to progress through that change arc. A. Maslow’s Hierarchy of Needs Individual behavior change theories are abounding. However, one that can further show the parallel of organizational change being akin to individual change is Maslow’s Hierarchy of Needs. This model describes how humans intrinsically participate in behavioral motivation (Maslow, A.H., 1943; Maslow, A.H., 1954)). This paper includes this theory of change to draw support for how an organization that is charged with taking care of ill individuals must also reflect on its own capacities and resiliencies just like the population it serves. It is also mentioned for the reason that as an organization builds resilience (financial, market diversity, brand loyalty, staff turnover, staff competence, limited litigations, patient satisfaction, etc), it can serve its population more fully if it values a holistic, patient-centered philosophy. These five levels of include the following: 1. First Level: Physiological Needs (e.g. food, warmth, rest, water) 2. Second Level: Safety Needs (e.g. security, safety) 3. Third Level: Belongingness and Love Needs (e.g. intimate relationships, friends, social support/network) 4. Fourth Level: Esteem Needs (e.g. prestige, feels of accomplishment) 5. Fifth Level: Self Actualization (e.g. achieving one’s full potential, including creative activities) 89 Figure 2.3 (Maslow, A.H., 1954) As seen in Figure 2.3 above, Maslow proposes a pyramid-shaped construct intentionally to highlight that basic needs provide a foundation on which to grow oneself, and, with those learned or gained attributes and/or securities, one can reach higher ordered psychologically attributes and securities that further fulfill one’s imagined dreams, deepest desires and satisfaction. The theory simply put is that the most fundamental needs of an individual must be met before one becomes motivated to ascend to higher ordered needs. Disciplines of sociology and psychology have documented the order of needs and the types of needs to be classified as a fundamental need or another. For example, in the first level of Physiological Needs, these needs are generally thought of as basic to human survival. If these needs are not being satisfied, it is very unlikely that the individual will move to comfortably or confidently seek the next level of Safety Needs. This level alludes to economic security, physical safety, job security, home security Self Actualization (achieving one's full potential, including creative activities) Esteem Needs (e.g. prestige, feels of accomplishment) Belongingness and Love Needs (e.g. intimate relationships, friends, social support/network) Safety Needs (e.g. security, safety) Physiological Needs (e.g. food, warmth, rest, water, shelter, health) Psychological needs Basic needs Self-fulfillment needs 90 (dynamic element that can be represented in the base or second level), and/or psychological safety/security (healed traumas, emotionally secure). These levels are considered “basic needs” or “survival-based” needs. Next is belongingness and interpersonal love needs. Some argue that filial or parental love is a basic need, especially in early infanthood (Bowlby, Ainsworth, cite); therefore, depending on the age of the individual, the capacity and motivation to move from one level to another is associated. Maslow purports that humans own an emotional need to be acknowledged and accepted by their peers or social groups. Belonging to a group provides a sense of identity, security in ways, and allows for the practice of vulnerability in interpersonal relationships. Not belonging to a group – whether family, religious, professional, sports, etc. – can lead to isolation, and even anxiety, depression and loneliness. This level being impaired can stunt the motivation or readiness needed to seek higher status, recognition or mastery in some area of life. Perhaps a part of an innate drive to rise in rank, for some, seeking more respect from others is more important for some than others. Sought out or not, this level is important because it speaks to humans’ needs for acceptance and recognition and self-respect and self-confidence, which bring about a state of freedom from the reliance of one’s worth on another’s appraisal. The comfort in this level prepares an individual for the desire for self-actualization. Maslow defines this as, “the desire to accomplish everything one can to become the most that one can be” (Maslow, A.H., 1954). This level could include aspirations of parenthood, mastering a sport, getting married, higher education, mastering a hobby, and the like. Through its five levels of change or classifications, the individual reflects to decide if the current level is satisfied enough prior to moving to the next level, and evaluates the effort that it may take to stay in one level versus the next. The ‘higher’ levels do not imply that they require more effort, but, ability to perform the next level does have some association with its predecessor. 91 More recently, researchers have articulated that these levels overlap more so than precede one another, as Maslow originally designed. B. Transtheoretical Model of Behavior Change Prochaska and DiClemente posited a new model of behavior change that provided a framework of stages to reach the desired change. It has been used repeatedly in different sectors and for different health issues, and has only some limitations. These stages include precontemplation, contemplation, preparation, action, maintenance, and termination/relapse. Early research has distributed change behaviors to 40/40/20% in the first three stages (Prochaska and Velicer, 1997; Prochaska and DiClemente, 1983). Many pictorials have been drafted for this model, however, below is one that is patient friendly, Figure 2.4. 92 As one can see. This wheel of change is cyclical and can also jump from stage to stage out of order depending on situational circumstances. What is transferrable about this model is that as it is applied to individuals, it may also be useful in organizational change because organizations make change through its human capital. Chapter 2: Literature Review Closing Prenatal care service design in the U.S. is historically complex. It’s structure, services, reimbursement and expected patient involvement in the U.S. mirrors more so a middle class, insurance- and system-centric structure not supportive of how, when and why low-income mothers access and navigate care. Systems expects mothers to engage in care when and how it’s available, rather than it starting where a mother begins and chooses to spend most of her time, energy and limited resources – at home and in her community. Being paternalistic and bureaucratic in the past, it has slowly evolved to be more woman and quality specific, from the design of research, the rights of women to choose their course of care, and to the services it offers women. Public health models of care theoretically are designed to address the physical, mental and social pillars of health and more recently have shifted toward a more empathic, community-based model. However, there is still much work to be done to this complex dynamic between system and mother as satisfaction of prenatal care and delivery experiences suffer, coordination and continuity of care lack, and rates of adverse birth outcomes remain. In Chapter 3, this manuscript’s research question, aims and methods of analysis are displayed to outline what was performed to assess and make organizational/systems change at DHS Women’s Health Services for perinatal health services enterprise wide. 93 Chapter 3 Transforming Prenatal Care at DHS: MAMA’S Neighborhood and Readiness for Change A worldview steeped in advocacy and social justice tethered this analysis. Creswell defines an advocacy worldview as one that, “contains an action agenda focused on the needs of groups in society that may be marginalized,” (Creswell, 2009, p. 9). As such, it is with this lens that this analysis’ consequent recommendations and contributions to practice reflect this worldview while still holding true to the objectivity necessary when examining the feasibility and implementation of an innovative program. This prompted the development of the policy question framing this analysis shown below. Policy Question: 1. What paradigm shifts and critical pathways needed for a traditional, hierarchal and complex bureaucracy within a government health care system to move to a mother centered model of care rooted in health equity? Study Aims: Study aims for this analysis were three-fold. They included: 1) to frame and agree upon the remodel conceptually 2) to assess the organizational readiness to change, and 3) to define the enhanced clinical components of care that would remodel and maintain the care to be mother centered. A conceptual model was used on which to base this analysis. Overarching principles of participatory, appreciative inquiry and collaborative governance undergirded the methods to conduct this analysis. To move through the organizational change, a behavioral change theory 94 framed the move from thinking about the changes needed to assessing the readiness to change to planning the needed changes to implementing and maintaining those changes. Tools used to perform the assessments included a 1) SWOT table; 2) readiness assessment based on Missouri Health Quality Works, and 3) AHRQ EvidenceNOW Key Drivers for Organizational Change. Emerged from this analysis were paradigm shifts and four critical pathways and three consequent phases of organizational change that included: 1. Laying the Foundation for Organizational Change (framing and assessments) 2. Building the House for Organizational Change (clinical service delivery enhancements/components) 3. Maintaining the Organizational Change (infrastructure build and arc) These outcomes informed what was learned, the gaps still existing in care and the implications of the aspects not being met and resulting recommendations for next steps. Study Conceptual Models To begin, this study based its analysis on one conceptual model called the, “ Mother- Centered Care Model (Moini, M., 2011; Moini, M., Saleeby, E, 2017) which offered the basis for the paradigm shift and subsequent organizational changes. Below is this model and a description of its contents. One major conceptual model was used to based this examination, and, three supporting models helped frame the planning of this monumental shift in the advancement of perinatal care. First, the model titled, “Mother Centered Care Conceptual Model” (Moini, M, 2012) was used to base the program upon. Through a participatory discussion between the Women’s Health Director and relevant parties, refining of the model took place to include delineation of the baby as a sphere 95 of influence, not an assumption in the “mother” at the center of the diagram. A description of the model was reviewed and edited to further describe the relationship of mother to her environment. This process was critical to centering the paradigm shift for all of perinatal health services. The refine model is below: Figure 3.1. Mother-Centered Care Model This prevention-driven and relationship-based model is grounded in three tenets: 1) the mother is the primary decision-maker in her own care; 2) mother-centered services and support will set the foundation for a healthy child; and, 3) a mother’s family and neighborhood are potential assets for support, and are primary influencers in her decision making. First, the mother being at Mother Centered Policies MAMA'S Neighborhood Family Baby Mother Figure 3.1. Mother Centered Care Model. Los Angeles County Department of Health Services, Moraya Moini, MPH and Erin Saleeby, MD, MPH, 2017. Adapted from Mother Centered Care Conceptual Model, Mother Friendly Childbirth Initiative Consortium. PHP Consulting, Moraya A. Moini, MPH, November 2012. 96 the center shifts the paradigm from health system-centric to a mother-centered one, which lifts up the responsibility of health care providers to meet mom where she begins in her readiness to address issues; requires empathic, trauma-informed practices; and, sets the stage for mom to be her own “driver” in her care and for activating her energy from within to help herself grow and succeed. Number “2” is explained further as the anchoring of a mother to a positive support system (whomever it may be) and encouraging her power from within to be the healthiest she can be, provides a solid foundation for her baby to securely attach, with the quality of that attachment being the emphasis. As well, putting baby next to mom displays the close proximity needed for optimal social and emotional development for baby, and conversely, the opportunity for humble learning during motherhood. Next, the model recognizes a mother’s family and peer support network are closest to her, and impact her knowledge, attitudes and chosen behaviors. Each mother’s neighborhood is seen as a component of the care plan and activated as the cradle that supports her in her pregnancy, birth and postpartum up to 18 months. This linked, collaborative model enhances the content of prenatal care by explicitly engaging community organizations in the plan of care, creating a true neighborhood for health with multiple pathways to care. Designing interventions that honor these concepts assist in supporting racial, cultural, linguistic and social awareness and humility. MAMA’S Neighborhood (Clinic, Community, and Visits) focused on activating the mother, her family and immediate social support and her ‘neighborhood’ agencies in advancing improvements in her care and health outcomes. Second Conceptual Model A second conceptual model guided the work of this analysis and care transformation. The Care Model for Perinatal Health was adapted from Wagner’s Chronic Disease Care Model (CCM). 97 Its six focus areas include: health system design, self-management support, delivery system design, community-based support, decision support and investment in clinical information systems. The CCM was created for the improvement of chronic diseases and their management, however, the tenets of a comprehensive, holistic approach to improved health outcomes, multiple entry pathways to accessing and utilizing health services, multiple players in supporting organizational and patient level behavior change, and patient engagement can apply to perinatal health. Perinatal health also is dependent on a multitude of factors psychosocially determined, and as such, systems and providers must be nimble during service delivery to meet patients where they begin behaviorally. Thus, the LA Best Babies Network (formerly known as the LA Best Babies Collaborative and Center for Healthy Births) adapted the CCM to be perinatal specific. Thereby, it identifies the essential elements of a health care system that encourages high-quality care. The model includes evidence-based change concepts under each element seeking to foster productive interactions between informed clients, who take an active part in their care, with providers, who are prepared with resources and expertise. This model provides the framework for the system level improvements that in combination will yield results in improving birth outcomes in each of MAMA’S Neighborhood Networks of Care. 13 13 From Improving Chronic Illnesses Care at www.improvingchroniccare.org "ICIC is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation". 98 Figure 3.2: Care Model for Perinatal Health 14 The Care Model for Perinatal Health Resources and Policies Community-Partnered Care & Enhanced Access Continuous Team Based Relationships & Care Coordination Organized Evidence Based & Patient Centered Care Family and Self Management Support Engaged Leadership Health Care Organization Prepared, Proactive Practice Team Supportive, Integrated Community Improved Outcomes Coordinated and Culturally Appropriate Care that is Patient-Centered, Timely, and Effective. * Adapted from the Chronic Care Model developed by Dr. Ed Wagner et al and LA Best Babies Network Informed, Activated Patient and Caregivers Partnerships Effective Programs Coordination Education Communication Outreach Care planning Care reminders Feedback/monitor outcomes Individualized plans Share date CQI strategy Evidence-based guidelines Specialist expertise Provider education Guidelines for women Team roles and tasks Continuity/Follow-up Referral networks Case-management Cultural / linguistic competence Support Woman’s role Information Planning & Coordination Leadership, goals, benefits, incentives Empanelment/ Registry & CQI These models assisted in framing the study, and set the stage for how it would principally implement change. An overarching philosophy of collaborative governance and appreciative inquiry were used to conduct the study. Without these, the organizational change would not have occurred, and it is why it is included as a critical pathway to organizational change, mentioned in Chapter 4, Study Results. The next section describes the Methods of this study and analysis inclusive of aims, tools of assessment, and framing necessary to lay the foundation for organizational change. 14 Adapted from NICHQ Care Model for Child Health 2004; Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4 99 I. Overarching Participatory Models of Inquiry and Organizational Change A. Collaborative Governance/Appreciative Inquiry Method Innovation is typically a massive integration of experiences, expertise, wins and losses, and focused passion colliding, exploding, folding and unfolding of ideas one is willing to try when the urge to disrupt a system exists. Achieving diffusion success for this innovation required its new director to build the buy-in needed to disseminate such a massive change in operations, clinical procedures and content. Key discussions were held with Executive Leadership at DHS, the innovation was shopped to the three DHS different birthing hospitals and their respective clinic obstetric medical and nursing directors, and a level of awareness of the crisis of preterm birth rates among DHS mothers with obstetric staff was raised. It required listening to staff say it was impossible, or something they always knew and wanted but didn’t have resources to address, and, in the end, fortitude and skill to know how to persevere and take several inputs, combine them strategically to sustainably support an output. An uphill battle, Dr. Saleeby forged new paths to making this new program a priority and new standard of care at DHS. When the program was funded, further strategic planning and setting a foundation for care transformation was required. To perform this, the Women’s Health Services Director next needed to onboard staff capable of moving this mountain. Thus, she hired a lead who came with a strong work history in LA County, background in maternal and child health, passion for mothers and babies, and expertise in negotiation, systems change, quality improvement and community engagement. Together, they tackled this enormous build. This set a series of objectives in action that followed the making of an ‘organization’ within an organization. 100 B. Theory Used to Make the Organizational Change: Transtheoretical Model/Stages of Change Prochaska and DiClemente created a model called the, “Transtheoretical Model of Change” (TTM) or “Stages of Change” that assesses an individual’s readiness to change a challenging behavior to a healthier one (Prochaska 7 DiClemente, 1983; Prochaska, DiClemente and Norcross, 1992). Similarly, this model was applied to this examination to approach change from an organizational level which inherently houses individuals who manage it. The stages of change utilized included: 1) Precontemplation (not ready), 2) Contemplation (getting ready), 3) Preparation (ready), 4) Action (facilitating change), 5) Maintenance (sustaining change), and [Relapse]. A diagram of this change theory is displayed below. 101 Figure 3.3: Transtheoretical Model – Stages of Change (Prochaska and DiClemente, 1983, Prochaska, DiClemente and Norcross, 1992) Precontemplattion • Not ready for change • Unaware of changes needed • No organizational efficacy Contemplation • Getting ready for change • More aware of changes needed • Information seeking • Low organizational efficacy Preparation • Ready for change • Making plans for action • Moderate organizational efficacy Action • Actively making change • Easily engaged • Motivated for refinements • High organizational efficacy • Gaining skills for resiliency Maintenance • Actively sustaining change • Motivating others toward change • Proactively seeking adaptability • High organiztaional efficacyand resiliency Relapse • Possibility when a new change is introduced • Strengthening ability to adapt is required to avoid relapse 102 Typically, in this model, it is a cyclical model rather than a static staged one because of the nature of behaviors to ask questions, banter decisions, and question whether the change is valuable enough to stay in. As well, it has been modelled as one that is dynamic and bounces around not in a stepwise fashion, because sometimes change is that unpredictable and as one build self- efficacy, the strength and comfort to get back up (be resilient) may start one back at preparation after a relapse vs. starting again at precontemplation. Etiher way, the stages are valid in that they document a construct of change that is useful when approaching change at the organizational level. C. Diffusion of Innovation/Care Transformation Method - Model for Improvement Method to Make Changes within Stages MAMA’S leadership engendered values that assisted with how it functioned and trained clinical sites to operationalize its new protocols. Continuing its commitment to facilitating, not autocratically deciding, change, leadership worked with sites to model the new brand and ethos. DHS referred to model principles of Everett Rogers’ Theory of Diffusion to understand how change might occur over time (Rogers, E., 1962, 2003). It understood that, at first, there would be some that would be considered “innovators” or “early adopters” to champion the change; and those individual staff were sought out. For those that contemplated the change and then became strong implementers, these staff would reside in the middle of the bell curve and be considered “early or late majority” implementers. “Laggards” were those that could either be spotted right away, and were coached carefully, as they could derail the change process through constant complaints. These staff were not problems, but more so, staff to dialogue with to dissect the reticence with so that more of what they needed to be convinced of change could occur. DHS leadership also was aware that over time there would be a natural tipping point of adoption of the change when 103 organizational efficacy was reached. To encourage this, rushing the change was not the aim, information and space to resist and debrief was provided, committed follow up from leadership was given, and institutional supports on every level were integrated. Likewise, to assist with mini-tests of change management, an improvement model was needed to conduct continuous quality improvement. Using methods from the Institute for Healthcare Improvement, (IHI) it used a Model for Improvement and the Breakthrough Series (Institute for Healthcare Improvement) to continue their original commitment of creating a Common Agenda and Language. Seen below, the model displays the Plan-Do-Study-Act used often in business to work through problems and set new, small goals to rapidly test. The Model for Improvement was used to implement change at sites to integrate MAMA’S Neighborhood protocols into daily clinical practice. The tests of change demonstrated how to adapt the implementation of MAMA’S Neighborhood to different conditions across DHS ambulatory sites. Using the Model for Improvement, together, MAMA’S leadership and sites evaluated intended and unintended consequences of the changes to maximize seamless implementation across DHS over time. Figure 3.4. Institute for Healthcare Improvement Model for Improvement 3 Key Questions for Improvement What changes can we make that will result in an improvement? IDEAS What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURES Test Ideas & Changes in Cycles for Learning & Improvement Plan Do Study Act 104 The Model for Improvement was chosen as the foundation of the improvement approach used in MAMA’S Neighborhood. The Model is built on three fundamental questions including: 1. AIMS: What are we trying to accomplish? 2. MEASURES: How will we know that a change is an improvement? 3. IDEAS: What changes can we make that will result in an improvement? Each of these questions were answered by MAMA’S leadership at the strategic planning level. This series of questions would serve as the guide along with the PDSA Testing method as the program’s Continuous Quality Improvement practice – further building the structural supports needed to launch such enormous policy and practice changes in the paradigm of care. IHI’s quality improvement worksheets (Institute for Healthcare Improvement, Breakthrough Series, accessed 2014) can be found in the Appendix. 105 Data Collection Overview The Transtheoretical Model (Stages of Change) was used to frame the organizational change necessary to make the paradigm shift a success. To better understand and define together the needed changes, three methods were used to assess the readiness and need for change, including: a SWOT analysis, organizational readiness assessment and a comparison of organizational capacity to change using the AHRQ’s EvidenceNOW Key Drivers for Organizational Change. To accompany those assessment tools and discussions, DHS clinical site profiles were drafted, clinical observations were conducted, and DHS Central and site-specific planning discussions ensued. As a result of these initial steps, production of care transformation guiding documents were drafted. With the long-term aim of improving birth outcomes, performing this analysis was necessary to develop a shared worldview and concrete translation of that into actionable components of care delivery to address systems change. As a result of this work, a translation of these data into a scalable, protocolized implementation manual was adopted by LACDHS for Countywide integration. Pre-Work: Internal Preparation for Change – Do Your Homework I. Perinatal Data, Landscape Analysis Current data was compiled from local, state and national databases to cull birth outcomes statistics and rates of social indicators of health. Reference sources included the National Center for Vital Statistics, Peristat, LAMBs, CMQCC, CDPH, LADPH Annual Health Report. Community based resource mapping was performed to lay out access points and potential network partners and gaps needing more research. Additionally, compilation of community directories was performed to complement the mapping of resources and assess the ability of 106 MAMA’S Neighborhood to build out the ‘neighborhood.’ Last, a clinic profile was generated to get an initial snapshot of demographics served, health outcomes, staffing structures, model of clinical flow, historical barriers to progress, and leadership structures. Next, leadership needed to make the commitment that HOW this program was launched was more important that WHAT was launched. Without this prioritization, shifting an engrained medical model paradigm to one of inclusivity, feeling welcomed and valued, and patience. The theme thus became to strive for a culture of relationships and trust building first, and over everything. Patients who lack trust with their providers are likely to change providers or have poorer outcomes, as well as, within teams, a fair and communicative working mode produces better results. Investment in the time it took to build this critical component of care provision became paramount. Step 1: Lay the Foundation for Organizational Change [Stage: Precontemplation] Critical to frame the analysis, the first step was to build a trusting relationship with all staff to lay the foundation to conduct participatory dialogues using principles of collaborative governance and community based participatory research. This was a necessary step to have prior to assessing starting points, creating a common agenda and making midcourse adjustments towards the desired, shared strategic plan to redesign perinatal care. Relationship building was the number one priority. The approach to change was humble, respectful and generative, and took place over a 3 month period, which was necessary to gain the trust and will of those site leaders and frontline who would be consequently be entrusted to uphold the model and implement the changes locally. Through collaborative, appreciative inquiry, landscape assumptions were delineated, the conceptual models aforementioned were discussed for their content, importance and relevance to 107 the redesign aims. Being comfortable to stay in this stage of “precontemplation” for as long as needed was a necessary to allow for trust, will and a partnership to be built. Then, as the progression to a second stage of change occurred, “contemplation”, discussions of discourse ensued to allow for the catabolic nature of recreating a design that would not only fit within the clinical structure, but be owned by site leadership. This process of discourse and agreement was a necessary step in setting the stage of sustainability. Continued monthly relationship meetings consisting of tracking data, process improvements made, and acknowledgements were upheld fiercely by the researcher and Executive Director/Women’s Health Director to honor that once new compliances are set, by theory of collaborative governance and community based participatory research (CBPR), it is the localized team that makes the change sustainable. To achieve a culture of relationships and trust first with providers and staff, MAMA’S leadership set a supportive meeting with each clinical site to build buy-in and a shared plan by a) presenting MAMA’S, b) discussing a common agenda that set visions and values and forecasted valleys and victories, c) establishing what was a “win” for all parties, d) performing 360 troubleshooting, and e) defining fair roles and responsibilities for all. Valuing the relationship over all made these meetings successful and challenges manageable when they occurred. MAMA’S leadership could have easily forced a change in clinical practice and operations due to previous non-compliance with Managed Care guidelines; however, playing that card would have served the old hierarchal, non-person-centered model, and eventually, it would have led to unsustainable change. It is psychology that consensus is important to come to when making changes, otherwise, by nature, humans resist because the change is not owned. MAMA’S leadership became facilitators of change. 108 Starting with staff first in modeling this facilitation of change assisted MAMA’S leadership when it came time to train staff on the protocol and intricate implementation steps of MAMA’S. With a renewed line of communication, MAMA’S leadership was able to ask the same of staff when working with mothers as patients. Staff was asked and trained to put building rapport and trust with the mother first before focusing on the pile of paperwork at intake. As well, this method was used to begin the process of determining the heavy stressors in mom’s life that could be negatively impacting her pregnancy. Helping staff understand that authentically showing mom that she matters in the journey to motherhood (first time or not) also became a fundamental teaching point. Understanding this circular process was essential to launching and sustaining the many hiccups to implementation that were experienced. Supporting this culture of learning rather than punishment served miles in terms of staff self-initiating the necessary perseverance, commitment, flexibility and creativity required to get the job done and re-brand Women’s Health at DHS. The key methods used were: Leadership as Facilitators not Hierarchal Authorities; Leveled Playing Field, Shared Decision Making; Build Buy in and Consensus on Aims; Common Agenda Setting (Vision, Values, Valleys, Victories); Clear Team Role and Responsibilities; Modeling and 360 communication; Establishing the “Win-Win” Step 2: Organizational Reflections [Stage: Contemplation] Second, once trust, conceptual model and the needs to change were clearly defined and documented, a review could begin together of each site-specific profile. Over a three-month period, consequent clinic observations and collegial discussions were held to further understand the regular practices, expectations and policies in place clinically, and to document the baseline 109 of change and starting point of change. At each site, discussion ensued to a) note clinical care workflow and site-specific nuances, b) meet staff, c) define care model transformations, d) barriers to implementation, e) define wins for sites and f) seek ambassadors of change. A key principle to further reduce psychological resistance, facilitate progress and prevent relapse was to build organizational (self-) efficacy at this point in the process of change (contemplation). First, at every meeting, a focus on maintaining the relationship occurred; this never veered away from the ‘agenda’. “No relationship, no change” was the modus operandi. Then, next steps ensued to define the issues and hardships, define the wins for change, define the ‘weight’ of the win (which is the pull or motivation to want the change [is the state or outcome of changing more desired than the current state?]), define fears and barriers, and imagine what the end result could look like. Step 3: Organizational Grounding [Stage: Preparation] Next steps for change were proposed at the times of a stage’s saturation. This readiness can be seen when the organization (and its teams) ask for or propose the next step themselves. Sometimes met with resistance, this dance between proposal and action is necessary so that the decision to change is owned by the organization (group of people/team). Knowing one has built enough of a relationship to begin the process of change is tricky. It is almost the “art” of changing. Years of experience assisting organizational through care quality improvements and creating countywide funding strategies were leveraged to gauge the point at which to transmute the energy of one stage to the next. Thus, to move further forward, an organizational readiness assessment was created participatively by the researcher and Executive Director to guide the understanding of DHS’ and 110 sites’ starting points (Appendix), and based off of Missouri Hospital System care transformation project called Quality Works. Components of this assessment included defining the needs; readiness to change; identification of time, resources and personnel; and, sustaining the change. As well, strengths, weaknesses/areas of improvement, opportunities and threats/external forces (SWOT) were assessed to gain an understanding of DHS’ starting point, and clinical environments’ starting points as its own ecosystem (Table 4.1, p.92). The SWOT accounted for decisional balances (pros and cons) of changing. To assist with possibly psychological resistance to change, assets-based terms were used during the SWOT exercise. For example, “Weaknesses” was morphed to “Areas of Improvement”, and “Threats” was morphed to “External Forces.” Since terminology is key, using these terms helped in building trust and softening the sphere needed to make changes. Used as a decisional support model, the TTM assisted in the preparation of thought, approach and action as site clinical engagement ensued to change. Last, framing of the new model’s grounding framework ensued to mark the beginning of the discussions of service enhancement creation. These framework pieces included: a) creating a driver diagram, b) defining the levels of mother-centeredness, c) defining the relationship of DHS to its “Neighborhood” as displayed in Chapter 4, Results. Step 4: Organizational Action [Stage: Action] Several collaborative exercises were performed to further assess and frame the change strategically so that organizational change could occur. Iterative exercises included documenting the following: a) the current and desired state of care delivery workflow with a Harbarian Process flowchart, b) the current state and desired states of care component in service delivery, c) the risk 111 algorithm and associated, relative “weights”, d) the current and desired states of care planning and referrals, e) the current and desired states of perinatal focused health education, and f) the current and desired states of neighborhood partnership building. Strategic steps were outlined to make those changes in five DHS clinical sites with more readiness, poor health outcomes regionally and a linked birthing hospital. Step 5: Organizational Change Sustainability [Stage: Maintenance (to limit Relapse)] Processes and policies were discussed and put in place to assist with sustaining the changes proposed in this strategic planning process. Participative discussions were held to decide on the structural supports needed to achieve and sustain change. The EvidenceNOW Key Drivers for Organizational Change created by AHRQ was used to compare and contrast the sustainability for change. A table was created that delineated the diagram’s key components and then three additional columns were added to delineate enhanced care component strategies implemented, and whether the aspect was met or labelled as a gap as compared to AHRQ strategies. Noted in Chapter 4 is the comparison table with added structural supports put in place to assist with maintaining the organizational change. Structural supports identified to make the desired care redesign for this organizational change included regular site leadership countywide meetings of different disciplines, site specific Collaborative Care meetings, dashboard of beginning metrics to define processes and desired targets, partnership matrices to coordinate “Neighborhood” partners, framework for health education and resiliency building, summary sheet profile for care planning, individualized readiness based care plan, and Rx for health. 112 Summary A participatory assessment and tracked change plan were necessary to make organizational change within an institution with complex bureaucracy, individual site differences structurally and practice wise (“site genotype and phenotype”), and enormity that generally halts progress. With patience and a philosophy of reflective change management, large scale systems change is challenging but possible. 113 Chapter 4 Program Adoption, Implementation Tools and Results Summary Now the standard prenatal package in DHS, MAMA’S Neighborhood provides pregnant women comprehensive prenatal services that emphasize care coordination and care planning that integrates the physical, social, behavioral and mental health needs of clients. The intake assessment guides patient risk stratification and subsequent care coordination. Patients receive enhanced clinic-based services including: 1:1 contact with their assigned care coordinators and social workers and a full range of prenatal and postpartum care at scheduled intervals based on the risk assessment and individualized care plan. Diffusing innovation within an antiquated health care delivery model at LACDHS required(s) the idea and a scaffolded plan, progressive and skilled leadership, commitment and capacity to be nimble and constant disruption of norms. While there are risks and benefits to innovation, the reward of being unique in a sea of the same, dedication to a holistic and justice- oriented model for women of reproductive age, and the challenges fought as a team were what kept the tank full for MAMA’S leadership. Like a startup, or running a marathon, many times it was mind over matter to achieve the seemingly impossible. Paradigm shifts and four critical pathways emerged as a result of this analysis. By using participative methods of planning, DHS was able to move from a traditional, provider-centric, insular model of prenatal care to one that was community based, mother-centered and community based. The shifts and pathways seen included the following: 114 Paradigm Shifts a) Ensure mothers” capacities and resiliencies stay at the center of care and all care change decisions b) Evolve from ME to WE at every level of service delivery: care planning among providers, care prioritization with mother, administrative operations and evaluation. Critical Pathways: 1) Ensure the values of the identified change are clear and agreed upon by consensus at the executive levels extending to (not down to) frontline levels using principles of collaborative governance, participatory inclusiveness and appreciative inquiry; 2) Utilize an evidence-based, data-driven and participatory model grounded in health behavior change theory and ecological theory to base the organizational change in, including methods of how to assess and make those changes from start to maintenance; 3) Invest in managing oppressive external forces of the system that frame and influence the organizational change, and feeding back regularly the victories and valleys of doing so to frontline staff; and, 4) Prioritize highly the basis for systems and organizational change not only on outcomes data, but on the mother’s levels of trust and satisfaction, degree of engagement, level of readiness to change, and current and influential and pervasive societal contextual factors. Without framing the care transformation these ways, perinatal care would have remained archaic, stale and disingenuous to the community it set out serve. The three phases of, “Laying the Foundation for Organizational Change,” “Building the House for Organizational Change” and 115 “Maintaining the Organizational Change” outline the results of this study’s methods for organizational change and perinatal care transformation. Phase 1: Laying the Foundation for Organizational Change I. Making the Case to Clinics Rationale for the Paradigm Shift Strategic planning discussions also resulted in defining five core assumptions gleaned from the perinatal data review. These Core Assumptions helped frame the rationale for the paradigm shift and are outlined below. Core Assumptions 1. Poor birth outcomes are often the result of multiple factors, including medical, social, and environmental determinants; 2. Screening and identification of high-risk mothers is inconsistently implemented, and intensity of service provision is not currently aligned with identified risks; 3. Care is fragmented and lack of coordination leads to missed opportunities to mitigate the determinants of poor outcomes; and 4. A comprehensive, coordinated public health approach that includes its three core pillars (physical, mental, social) is required to address the issue responsibly. 5. Supporting mothers to be healthy, resilient, connected and prepared sets the foundation for a healthy newborn and consequent infant cognitive, social and emotional development. II. Organizational Readiness Transformation of perinatal care was achieved through a participative strategic planning process. Five clinical sites were chosen for the first wave of system care transformation. The Women’s Health Centers were chosen within those sites, with three of those being the County’s birthing hospitals, and included: Harbor UCLA Medical Center (birthing) in Torrance, California (SPA 8), Martin Luther King Jr. Outpatient Center in Lynwood, California (SPA 6), Hubert Humphrey Comprehensive Health Center in Los Angeles, California (SPA 6), LAC+USC Medical 116 Center (birthing) in downtown Los Angeles, California (SPA 4), and Olive View Medical Center (birthing) in Sylmar, California (SPA 2). Organizational readiness assisted the decision of where to begin care transformation activities. Further, the rationale for choosing these five clinical sites were that they met the poor regional perinatal health statistics, high prenatal patient census, ability to access outcomes data, and met the minimum threshold for organizational readiness. DHS and each sites’ joint assessments are seen in Table 4.1, p. 92. Other concerns revealed in the assessments included a lack of assertion that systemic racism could be associated to the current rates of preterm birth and low birthweight. However, a need to address poor birth outcomes was overwhelmingly agreed upon. The agreement to use the proposed MAMA’S Neighborhood project as a means to improve birth outcomes was met with some reservations including: 1) comfort and confidence (organizational self-efficacy) to make all the changes being proposed; 2) competing priorities at clinical sites, 3) physician site leadership buy in, 4) appropriate staffing to implement the needed changes, 5) bureaucratic budgeting process that yields a lengthy hiring process, 6) ownership of item positions and consequent supervision of item positions; 7) looming electronic health records migration whilst making care redesign changes; and importantly, 8) frontline buy in. 117 Table 4.1. Organizational Readiness Assessment Element Assessment Yes Yes, with reservation No Defining the Issue Awareness of statistics of preterm birth, low birthweight and obstetric, psychosocial and systemic issues contributing to those poor outcomes ✓ [no tie to systemic barriers] Agreement to address the need to improve preterm birth and low birthweight ✓ Readiness to Change Agreement to build a strong evidence-based care quality improvement project as an appropriate strategy to address patient needs ✓ [organizational self- efficacy and competing priorities] Agreement that now is the right time to plan for and implement the birth outcomes care quality improvement project ✓ [EHR, staffing, bureaucracy, clinic flow redesign] Staffing and Tools Agreement from Executive DHS Leadership to allot staff to plan for and implement the birth outcomes care quality improvement project ✓ [DHS Health Director sign off] Agreement from Women’s Health Executive Director to allot staff to plan for and implement the birth outcomes care quality improvement project ✓ [WH ED sign off] Agreement from Clinical Sites Leadership to staff participation in the planning for and implementing of the birth outcomes care quality improvement project ✓ [bureaucratic budgeting process, lengthy hiring, ownership of item 118 positions, supervision of item positions] [EHR upcoming, physician champion, staffing, bureaucracy, clinic flow redesign] [frontline buy in, clinic flow redesign feasibility, site leadership to shepherd] Agreement from Clinical Site Leadership allow time from frontline staff in the workday to implement new strategies (shift some priorities) and continue the work necessary to achieve project deliverables ✓ [competition of time and meeting site mandates] Possesses tools (assessments, leads, staff, tracking, monitoring) to make organizational change [no system in place] Care Model Consensus Agreement to the framework presented of the project that includes: A Mother-Centered Model of Care, Collaborative Care, Continuous Quality Improvement, Serial Comprehensive Assessments and Risk Stratification, Care Coordination and Navigation, Resiliency Based Health Education, Postpartum Supportive Care ✓ [enormity, staffing, time away from patients, meeting service provision goals] Acknowledgement Ability to reward positive steps made to change the system [no system in place for acknowledgement] 119 SWOT Results Key strengths of the program included being evidence based, grounded in principles of shared decision making, mindful of mothers’ complicated and stressful lives, risk stratified to offer a cost effective and efficient framework to manage caseloads, more accessible via home visits, and multi-disciplinary. Most salient strengths expressed by staff and seen in clinic observations were nursing staff understanding the importance of attending to a pregnant mother’s psychosocial needs as they relate to birth outcomes; local leadership lean to buy in to changes in clinic workflow; DHS Executive Leadership support for change; commitment by Executive Leadership Director to strong health education and care coordination staffing, supported ongoing training and coaching, and integration in all new clinical policies, protocol, and practices/workflow; and the ability to add Care Coordinators, Social Workers, and Health Education staff (although limited in number) to round out typical clinical care. Key weaknesses or areas of improvement noted by staff and observed at various meetings included: making change real-time as normal clinical functions competed; changing/lacking local physician champion; slow build of a nurse champion; added staff were siloed at first despite introduction and reasons for change made (no work space, slow confidence on how to integrate them in to care); changing Health Information Technology/Electronic Health Records platforms, data migration, and graduated ramp up; hard start to adopt a seemingly medically based model of risk stratification for a largely psychosocially based care implementation; unaligned electronic health data systems ready for holistic care that must be collaborative to retain model fidelity; not enough staffing upfront to meet the demands of risk stratified case mix, complex care planning and supportive follow up services on intensive cases (no staffing model approved of inverse 120 pyramid staffing to withstand start up pressures); and, the constant rotating nature of medical residents and variable-to-stable physician lead/attending in clinic. Key opportunities of change and adoption of innovation were noted as the potential improvement of outcomes, brand, and patient and staff satisfaction. With pressures from entities measuring patient outcomes and the need for Managed Care compliance, it was noted that therein lied the opportunity, or motivation, to tailor care; if patients are doing better, the hospital scores do better, and then its brand and demand grows. In the end, leadership staff felt opportunities weight out the risks, threats and work burden required to make this tectonic shift in perinatal care at the County. Key threats and complex external forces to achieve institutional evolution ascertained in the clinical flow observations and collegial, structured and participatory planning conversations within were noted as maintaining a fidelity to its model principles of being mother friendly and mother centered, as defined as: very long hiring processes and practices at DHS; line staff blaming the “victim” and not contextualizing lives or structural and systemic racism in health care; cyclical sways of prioritization of workflow; clinical needs over mother/patient needs; low prioritization of community regional liaisons to create and maintain a network of linked neighborhood social care partners (even though this was largely a psychosocial care program, inherent in the brand name, “MAMA’S Neighborhood”); lack of a robust data collection system that would capture referral conversion rates; slim infrastructure to support team based care in clinic and field; lack of accessible after hours for mothers and families to engage in care; lack of accountability framework built in for health care staff treatment of mothers; and relapses to old ways when under clinical, staffing, and leadership pressures. It was noted that the bigger a service provider gets, the harder it must work to maintain model fidelity, which starts with institutional values of knowing one’s 121 service population – mothers – in more ways than at a population-based level. Decision at policy levels often use aggregate data only, which prevent a system from fully knowing its end user. 122 Table 4.2. SWOT Analysis STRENGTHS WEAKNESSES (AREAS OF IMPROVEMENT) Individual Level 1. Mother’s community ties Family Level 1. No regulation not allowing family involvement in appointments or classes Organizational/Network/Community Levels 1. SPA regions to help organize outreach 2. Decent number of providers in the neighborhood (not enough capacity though sometimes) Systems Level Design 1. Had external advisory involved 2. Two-woman team with similar mind and frame for concept and implementation 3. Previous experience doing something very similar of key person managing implementation 4. Brings physical, mental and social together, acknowledges non-clinical issues as impactful in mother’s physical health – true public health approach 5. Leveled playing fields of important actors in care delivery – i.e. front desk, specialty care, admin staff, nursing, care coordinators, social workers - at all levels of education and experience; value for lived experience; value for other disciplines 6. Build capacity to serve women more comprehensively 7. Risk stratified Staffing 1. Staff was hired on permanent status Evaluation 1. Had mandate from grant for dashboard of metrics Individual Level 1. Systemic barriers to care: transportation, child care, low income, housing and food insecurity, 2. Unassessed protective factors 3. Change of priorities of moms once baby is born, engagement slows down Family Level 1. Noninvolvement of father in more ways than PNER classes 2. No labor/birthing prep class 3. Separation of care with pediatrics; no integration of newborn check ups with postpartum check ups Organizational/Network/Community Levels 1. No mechanism for addressing psychosocial issues 2. No coordination of care 3. No care navigation between specialties & community partners external to DHS 4. No comprehensive postpartum assessment 5. No tailored way to engage mother after delivery within 40 days 6. No continuity of insurance management 7. No summary of care, or care profile for medical provider to refer to 8. No risk stratification to assist with operational efficiency 9. No usage of care quality improvement activities 10. No use of social workers at their highest license (therapy) 11. Use of MFM specialist for all OB care 12. No staffing to accommodate for care coordination 13. Attending physician was completely in charge with no dispersion of authority to care manage to other members of the site 14. No unit-based team designation 15. No collaborative care methods for case review 16. No nursing staff to run birthing tours at hospital Systems Level 123 Pan-Policy Level 1. Part of a national demonstration project 1. No population health monitoring of chronic diseases in the PN or PP 2. Weak ties with primary care and pediatrics 3. Weak ties between all County Departments (DMH, DPH, DCFS, Probation) Design 1. Limited definition of mother centered, it is maternity centered so that is different (what does maternity centered actually mean?) 2. Skipped birthing experience and period, not included in implementation activities 3. External advisory dropped off when we grew and needed more consultation and new WPC grant did not support consultants on race equity, TIC strategy building, 4. Coordination of care planning between CCs and clinical 5. Way to coordinate care electronically that was timed with grant, also not user friendly Infrastructure Staffing 1. Not enough supervisors were approved for hire, left CC staff feeling lost, go rogue, as the number of staff increased 2. No outreach, neighborhood builders, no one to intensely recruit and manage org partners and make a neighborhood network of care 3. No one to build the teams in the WPC MCTs Pan-Policy Level 1. Drop from MC after 6-8 weeks PP, no staff to work on re- enrollment OPPORTUNITIES THREATS (External Forces) Individual Level 1. Leverage her protective factors Family Level 1. To engage family Organizational/Network/Community Levels 1. Build a neighborhood network of care for mom Systems Level Individual Level 1. Mother’s competing life demands 2. Ambivalence 3. Mother’s mood 4. Mother’s use of substances 5. Mother’s Family Level 1. Father’s or family’s opinions of pregnancy 124 1. Sustain staff b/c its positions were petitioned to be full time perm items, not grant funded 2. To change systems at DHS 3. Meet managed care guidelines 4. Get enterprise wide quickly because of grant and executive level buy in quickly because of grant 5. Prove a risk stratified model of care works 6. Large system to back implementation needs Pan-Policy Level 1. Interviewed/influence on how federal funding can be modified 2. Influence care coordination policies at the federal level Organizational/Network/Community Levels 1. Rarely have staff managing outreach or partners 2. HIPAA reticence 3. Site buy in slow and resistance to change 4. Changing MD leadership, reduces continuity of provider champion Systems Level 1. Competition in provider landscape 2. Pressures of operational efficiency metrics (cost, profit) 3. Electronic health records migration 4. Scale up too fast 5. Case loads too high for intensive case management 6. Staying in touch with mothers b/c don’t have time to do follow ups in the clinic schedule Pan-Policy Level 1. Federal funding priorities 125 III. Collaborative Partnership To show a systems view of how care would work together to clinical sites and “Neighborhood” partners’ presentations, a diagram was created that mirrored original conceptual models that put mother and her community at the center of care (new paradigm) – rather than the provider or health care system (old paradigm). This can be seen in Figure 4.1. 126 Figure 4.1. Multisystem Construct of MAMA’S Neighborhood: How We Work MAMA'S Neighborhood Vision All women have access to holistic care that is: coordinated, comprehensive, continuous, compassionate & culturally- attentive Mission To support pregnant women through holistic care that improves maternal & birth outcomes, and supports healthy infant development DPH Aim: Partnership for Healthy Births - CPSP certification - Educational materials - Health Equity DHS Aim: Mother-centered, Coordinated Holistic Care - Medical Care @ DHS Women's Health sites - Care Coordination - Mental Health/Therapy - Home Visitation (2017) - Education and Resiliency Building DMH Aim: Bridging Mental Health - Psychiatry, intensive therapy for SPMI - Psychology PhD Fellows for integrated care COMMUNITY BASED PARTNERS Aim: Seamless, Linked Care - Substance abuse, housing, food, partner violence, other mental health, mother education and support groups 127 IV. Driver Diagram To guide systems improvement, a driver diagram (Figure 4.2) was created that delineated an end goal of reducing preterm birth, but more importantly outlined the major factors preceding that goal, and thereby, the basis for implementation activities. Key to this diagram was a focus on the “Processes” that support an activated mother and an activated provider and system. With these emphases, it was the goal to conduct care differently such that it produced a system more ready and tailored to the mothers it serves, providers that were more knowledgeable, ready and willing to meet mothers where they begin (rather than talking at them and setting unrealistic expectations), and mothers more trusting of the system and inspired to address toxic stressors affecting their pregnancy. 128 Figure 4.2. MAMA’S Neighborhood: Driver Diagram and improve maternal and infant mortality 129 V. Core Principles & Levels of Mother Engagement in Care and their Associated Tenets As such, it was defined that several system-level and operational changes were needed to mirror the principles of the Patient-Centered Medical Home. Therefore, as a result of iterative planning discussions of the DHS’ PCMH principles, Maternity Centered Medical Home principles were crafted to reflect the operational changes needed to anchor the transformation of care delivery for the model. These MCMH Core Principles are outlined below. Core MCMH Principles • Service delivery within a maternal medical home can be complemented by community-based home visitation that is equally as comprehensive and mother- and baby-centered; • Service provision by multidisciplinary care teams will offer improved care coordination and patient access; • Patient-centered care coordination anchors service delivery for high-risk women, with service intensity determined by risk score; • Health Information Technology (HIT) utilization is required for population management; & • Continuous quality improvement processes underpin model implementation to track process and outcome measures and support rapid-cyclical improvement. Tenets of MAMA’S Neighborhood Maternity Centered Medical Home were also outlined to display the difference between usual care and the expected improvements to enacting maternity centered care. As such, the Maternity Centered Medical Home was designed to be one equally weighted actor of many in the sphere of health and wellness for the mother. Equal to other actors, such as community-based organizations matching her social care needs, the MCMH is meant to function as the primary anchor for coordinating care regarding the mother’s needs and preferences. Staff at the MCMH ‘work’ for the mother, in that, they respect that she is the driver of her own care, and that staff is there to support, educate, facilitate, navigate, with her and lean in when their expertise is relevant and needed. As the primary actor, Care Coordinators were also designated as lead when coordinating (supporting synergy) between all team partners who provide care internally and externally with the Neighborhood. Moving away from a hospital centric model that 130 was top-down, urgent and emergent, and “high tech-low touch”, DHS WHPI created MAMA’S Neighborhood to level decision making and hierarchy in the Mother-Provider relationship, and make care about her rather than the system, compliance, and protocols. Without mother as the central actor, a system so enormous can overshadow her, miss critical pieces of her life related to care, and minimize her worth. Retention and outcomes were noted as issues that could suffer when relationships and treatment are not valued more than time quotas for appointments. As well, MAMA’S Neighborhood shifted the paradigm of care to be “mother centered” and more responsive to mothers’ care and stressors impacting healthy births. To further evolve this shift to reflect mothers’ intimate and thoughtful perspective on care, two additional columns of thematically interpretive comparisons are delineated. The first column represents the old way of delivery maternity care at DHS; the second column includes shifts made to be more maternity centered; the third and fourth columns advances the concept of maternity centered to be mother centered and partnered. The following depicts the care transformation tenets that DHS agreed upon to achieve maternity centered care. 131 Table 4.3. Tenets of the Different Levels of Mother Centered Care Before Now Next Next PATIENT CARE AS IS With MAMA’S Neighborhood Model of Care Shifted to MATERNITY CENTERED MOTHER CENTERED MOTHER LED OR MOTHER PARTNERED My patients are those who make appointments with me Our mothers register with DHS as their maternity home and are offered both on-site clinical and home/community-based visitation by DHS team. Emphasis is on paying for transportation and childcare during any prenatal, childbirth or postpartum appointment; appointments times are expanded to include nights, weekends. Support the creation of: - Mother Advisory Board - Mother Mentors Project - Mother Seats on Existing Care Planning Meetings - Social Media Tailored to mother with Links to popular and Evidence Informed/Based programs, Blogs/Vlogs - Centering Parenting (CHI) to implement Postpartum Positive Parenting and Motherhood Adjustment - Motherhood Assessment Scale (identify) to include in Postpartum Instrument Standard OB protocols determine care We systematically assess our mothers with a standardized comprehensive clinical and social care assessment that identifies strengths and areas of improvement needed of the mother, and create care plans that are tailors to her needs. Emphasis is on collecting mother care satisfaction feedback that informs how obstetric care is delivered; expands care to include Doula services in childbirth; enhances postpartum/interconception care to include Doulas specifically for highest risk home visiting clients in the postpartum period up to 18 months. Patients are responsible for coordinating their own care A multi-disciplinary team of clinical and social care professionals coordinate internal and external referrals that are tailored to mothers’ individual needs based on risk level. Emphasis is placed on assessing mother’s readiness to address current psychosocial issues considered significant stressors in her life. Patients are given slips of paper with referral information for We actively engage and connect a multi- disciplinary Neighborhood Network of Care comprised of health and social care providers Emphasis is on investment in a case/care management electronic platform that forecasts, prompts and assists the Care coordinators 132 community-based services which link together pathways of care for the mother. in following, prioritizing and outreaching to their mothers in a risk stratified but reality based way that only unfolds over time, with built rapport and built capacity of mother to address the issues. We assume we deliver high quality care because we are well trained We utilize evidence-based measures and quality indicators to aid in continuous quality improvement activities that support better perinatal clinical and psychosocial outcomes. Emphasis is on a CQI dashboard that is addressed monthly with Care Teams and created by the Care Teams. We review patient charts at the time of visits to look for gaps in care We utilize electronic patient tracking and empanel mothers to support continuity of care and identification of strengths and gaps in care. Emphasis is on tightening care continuity from Obstetrics to Inpatient to Postpartum to Pediatrics with dyadic care programming, in-clinic insurance enrollers and It’s up to the patient to tell us what happened to them We utilize a summary sheet profile and individualized care plan that summarizes standardized screening tools and allows for informed follow-up. Emphasis is on including protective factors, strengths of mom, building her support network, motherhood preparation and adjustment (largely emotional and mental health related), addressing transgenerational traumas with a trauma informed implementation framework, Clinic operations center on meeting the doctor’s needs We offer a proactive clinical and social care team that honors the perinatal period as a critical window for intervention and improvement for mothers. Emphasis is on smaller case loads; capping Enhanced Care Coordination of highest risk and co-locate (rather than refer/link) other uncapped home visit programs within DHS clinics so that medical and psychosocial are not fragmented (e.g. Shields for Families, NFP, EHS have desks at DHS clinics and conduct business as such). 133 Phase I Summary Assessments were conducted to provide a basis for change. Through these collaborative actions, foundational aspects of MAMA’S Neighborhood’s mother centered care model were derived. Laying the groundwork first allowed relationships to be built first so that change could occur in partnership and without resentment. Ownership of change became possible with this shared decision-making phase. Phase 2: Building the House for Organizational Change I. Defining the Service Delivery Change Package MAMA’S Neighborhood change package was delivered to clinical sites as an operational guide. Through the various support meetings held together, MAMA’S leadership and site staff worked through these components and tailored the steps needed to operationalize these goals at their sites. The following is a list of change concepts that were prioritized in this planning process. Table 4.4. Mother Center Service Package Component Change Concept Description Component 1: Continuous Team- Based Relationships Assure the delivery of effective, efficient, client centered, and safe clinical care. • Define roles, distribute tasks, and provide appropriate training to team members. • Ensure links to appropriate perinatal, neonatal, and specialty care providers for high-risk consultation, lactation support, and postpartum follow-up. • Ensure that educational and community resource materials are up- to-date, organized and available at each prenatal visit, as well as between visits. • Assure improvement in care by documenting and communicating with the practice team, referral agencies and the woman about her on going, evidence-based Plan of Care. • Provide clinical case management/home visitation services or referrals to evidence-based programs or other follow-up mechanisms for women/families with complex needs. 134 • Provide culturally and linguistically appropriate care at all points of contact. Component 2: Mother-Centered Interactions Support women and their families in the management of their health and health care before, during and after pregnancy • Emphasize the woman's central role in managing the health and well-being of the family unit. • Use effective self-management support strategies that include assessment of self-management knowledge, goal-setting, action planning, problem-solving and follow-up. • Organize internal and community resources to provide ongoing self-management support to women before during and after pregnancy. • Develop with the woman a written, collaborative and culturally appropriate Plan of Care that includes identified support person(s), resources and needs, interventions, self-management goals, and recommended follow-up. Component 3: Engaged Leadership Create a culture, organization and mechanisms that promote safe, high quality care. • Develop agreements that facilitate efficient and timely care coordination* and communication within and across public and private health and social service agencies to ensure appropriate and safe perinatal, postpartum and women’s health care according to standard guidelines. • Engage senior leadership and use an effective improvement strategy with measurable goals to support improvement at all levels of the organization that result in comprehensive system change designed to improve perinatal, postpartum and early infancy care with a focus on safe and equitable care for all. • Establish and encourage on going, transparent systematic handling of errors and barriers to quality care. • Integrate the National Standards for Culturally and Linguistically Appropriate Services (CLAS) throughout the healthcare system. Component 4: Continuous Quality Improvement (CQI) Strategy Choose and use formal models for CQI • Establish and monitor metrics to evaluate improvement efforts and outcomes and provide feedback. • Enable feedback to team and for external reporting on processes of care and population outcomes. • Obtain feedback from patients/families about their healthcare experience and use information for quality improvement. • Ensure that providers, staff and patients and families are involved in CQI activities. 135 Component 5: Enhanced Access Understand patient supply and demand and balance patient load accordingly. • Promote and expand access by ensuring that established patients have 24/7 continuous access to their care team via phone, email or in-person visits. • Provide scheduling options that are patient- and family-centered and accessible to all patients. • Help patients attain and understand health insurance coverage. • Follow-up with patients within a few days of an L&D triage visit or hospital discharge. Partner with community to meet the needs of pregnant women, their families and children. • Form partnerships with community coalitions, organizations and agencies to support and develop interventions that fill gaps in needed services for pregnant women and their families. • Advocate for policies to improve women’s health and early infant health and development before, during and after pregnancy. Component 6: Care Coordination • Directly link patients with community resources, facilitate referrals and respond to social needs. • Proactively track and support patients as they go to and from MCMH and community-based services • Test results and care plans are communicated to patients. Component 7: Organized, Evidence-Based Care Ensure clinical care that is consistent with scientific evidence and within the woman's informed preferences. • Provide planned care and follow-up based on identified needs and risks, and according to evidence-based guidelines for content and timing of care. • Embed evidence-based guidelines for assessment, screening, interventions and follow-up into daily clinical practice. • Share evidence-based guidelines and information with women and families to encourage their participation in care decisions. • Utilize provider education strategies proven to change practice behavior. Author: 2 nd Adaptation: LACDHS, Women’s Health Programs and Innovation, 2013. Adapted by Health Management Associates for Los Angeles County Department of Health Services, 2010 from “Change Concepts.” The Safety Net Medical Home Initiative. Qualis Health, The Commonwealth Fund, Improving Chronic Illness Care. www.qhmedialhome.org. 136 II. Components of Clinical Care Transformation Identified Overview Multiple components of clinical care transformation were identified to support the service package mentioned above. Beyond its strategic framing , x number of components were decided upon, including: standards of practice/protocols, methods of communication, comprehensive assessment, risk algorithm for stratification, mental health coordination and integration, psychosocial follow up schedule, care management process and review, external relationships and community partners, care coordination and navigation, health education and resiliency building, linked care referrals and a social care response mechanism for basic needs. Each were operationally defined and implemented incrementally and collaboratively. 137 Table 4.5. New Components of Care Transformation Identified Before and After Comparison of Prenatal Care Elements *element of or responsive to health equity Prenatal Care Elements Traditional Prenatal Care Pre-MAMA’S Neighborhood at DHS Innovative Prenatal Care Post-MAMA’S Neighborhood DHS Strategic Aims ▪ none ▪ Vision, mission and values statement created and published ▪ Strategic objectives and plan developed, implemented, and with intention to evaluate effectiveness Framing ▪ none ▪ 1 driver diagram ▪ 1 evolving standards of practice, implementation manual ▪ Standards of Practice ▪ Clinically related protocols individually written for specific disciplines ▪ No emphasis on psychosocial care ▪ Implementation Manual written to frame and guide frontline work within a conceptual model and implementation improvement models Communication ▪ Top down, most educated to least ▪ Exclusive ▪ Hierarchal ▪ Shared decision making ▪ Leveled playing field of disciplines ▪ Inclusive Assessments ▪ Medically related ▪ Light touch on other psychosocial issues if a CPSP providers, otherwise, not addressed as evidenced by mainstream private insurance models ▪ Not typical to use validated, evidence-based scales ▪ Psychosocially focused ▪ Use of validated scales within ▪ Linked to a risk calculator ▪ Trained to have directions and set up on sections to ask permission from the patient to ask personal questions ▪ Directly linked to individualized care planning ▪ Serially implemented to ascertain periodic progress or regression ▪ Summarized on the Summary Sheet/Care Profile Risk Stratification ▪ none ▪ All cases were treated with urgent and emergence of issues ▪ All patients were seen by a specialist rather than a cost-effective graduated model of generalist to specialist ▪ Weighted score resultant from comprehensive assessment ▪ Assists with operational efficiency and care revew 138 Mental Health Coordination and Integration ▪ Integration of psychology clinical interns for gynecologic care ▪ No consult available for psychiatric care and medication management by OBs ▪ Mental health redesign to integrate psychiatric care consults ▪ Training to OBs for medication management ▪ Integration of care between DMH and DHS Psychosocial Follow Up Schedule ▪ none Care event schedule that delineates “what to do when and by whom” Care Management and Review ▪ none ▪ 1 care management review tool, 321 ▪ Collaborative Care group meetings that are multidisciplinary External Relationships with Community Partners ▪ Non-existent, unless a CPSP provider, but depth and breadth of these vary greatly between a FQHC model and private doctor’s office, largely unaudited or monitored for these aspects of care. ▪ Not leveraged for recruitment ▪ Aspect of care given a name, “Neighborhood Network of Care” ▪ Supported by Tiered MOU contract to solidify partnership ▪ Bidirectional ▪ Branded logo window decal for partner organization’s display ▪ Network is managed through nurtured CSR-like (customer service relations) business model principles ▪ Inclusion is evidenced based ▪ Leveraged for systematized referrals into DHS MAMA’S using a business CSR-like model of client acquisition Care Coordination ▪ Non-existent to very little in quantity ▪ Referrals to hospital social work ▪ Unsupported from referral to linkage ▪ Often old lists of resources provided to patients ▪ Not mindful of patient health literacy ▪ 1 individualized care plan ▪ 1 readiness and ranking assessment ▪ 1 rx for care ▪ Health Education ▪ none ▪ Individually integrated into Care Coordinator assessments and follow up, and via nursing during clinical visits ▪ Group classes taught on site weekly o Optional but promoted heavily amongst clinical staff o Inclusive of fathers, partners or supportive others o Resiliency based o Hybridized model with prenatal education and resiliency principles based in cognitive 139 behavioral methods/problem resolution/regulation o Promoted for stress reduction, mood management, social support and self efficacy improvements o Facilitated by health educators o “Pop ins” from medical staff (nurse, resident, nutritionist, social worker) to encourage shared mental modelling, answer medically related questions, care continuity Extended Care Referrals ▪ Usually made by a nurse or licensed social worker internally to specialty care or externally via unmanaged channels, or not at all ▪ Unidirectional ▪ Note possibly documented in patient’s chart in a text, non-abstractable field ▪ Absence from care model is not evidence based ▪ Spearheaded by Care Coordinator ▪ Multidisciplinary directory linked to individualized care plan ▪ Regionalized by zip code ▪ Filtered by domain issue area ▪ Monitored “need it” “want it” “have it” triad of mother- driven, readiness-based care management ▪ Resulted in a Prescription for Health, “Rx for Health”, that then, output the chosen psychosocial care organizations and contact details chosen by the mother for her incrementally iterative and multidisciplinary, multisectoral care plan that would then be actively coordinated and navigated by the Care Coordinator and Mother together ▪ Response to Basic Needs ▪ none ▪ Aspect of care given a name, “Baby Boutique” ▪ System created via donors focused on mothers and babies ▪ Based in education and social support ▪ Acknowledged as an essential aspect of care that addresses the realities of financial stressors on physical health 140 III. New Clinical Care Workflow Overview Clinical workflow was documented before and after organizational change. Prior, care was mainly delivered by costly high-risk specialists under a medical model of care with limited support and accountability to implement the Comprehensive Perinatal Services Program (CPSP) mandated by managed care organizations insuring Medi-Cal mothers. With a changed emphasis towards intentional inclusion of psychosocial care and the staffing it required, clinical care workflow was able to change. Figure 4.3: Pre-Care Transformation Workflow Check in Basic nursing assessment/preg. test Lab work See MFM (obstetric specialist) CPSP assessment by nurse Referrals provided Obtain next medical care appointment no psychosocial follow up no community partnerships 141 Figure 4.4. New Clinical Care Workflow 1 st Visit 2 nd Visit Check in Care Coordinator Welcome Options Counseling/Mother Asst of Goal Comprehensive Psychosocial Assessment Individualized Readiness Based Care Plan Rx for Health Linked Referrals and Plan Informed nursing assessment/preg. test/lab work Obtain next medical care appointment Check in Care Coordinator Welcome 1st Follow Up Appointment with Care Coordinator Nursing follow up OB Generalist/Midwife medical appointment ICP Summary Sheet Reference Sign up for Prenatal Health Education and Resiliency Classes Optional Reconnect with Care Coordinator Obtain next medical care and Care Coordination appointment 142 Description of Enhanced Care Components Comprehensive Psychosocial Risk Stratified Assessment The risk stratification algorithm for mothers was developed by the Executive Steering Committee at the beginning of the Strong Start – MAMA’S Neighborhood initiative in 2013. Through a process of collaborative discussion and literature review, determination of psychosocial risk domains, validated scales and weighting of those domain specific scores to create a Global Risk Score (GRS) was completed. Currently used, and now the standard of care, the GRS provides a framework for care coordination, follow up frequency, huddle discussions with nursing and provider staff, and case reviews during Collaborative Care meetings. The GRS’ are: level 3, extremely high-risk (follow up weekly); level 2, moderately high-risk (follow up monthly); level 1, relatively stable (follow up trimesterly). Risk stratification of care are designed to be an initial guide for service intensity and time related. The GRS was designed to stratify mothers’ risk level by the number and type of issue presented/shared. For severe situations, the risk calculator was designed to be sensitive and specific enough to place mom in the appropriate strata. Case load distributions per Care Coordinator roughly equal 60% level 1, 30% level 2; and 10% level 3. Nine risk domains comprise the comprehensive assessment and include: 1) Alcohol and Substance use 2) Tobacco 3) Interpersonal Violence 4) Depression 5) Anxiety 6) Social Support 7) Housing insecurity 8) Food insecurity 9) Biomedical history and complications Comprehensive, serial assessments, serial individualized care plans (ICP) and prescriptions for health (Patient Rx for Health) will guide the MCMH team in the delivery of appropriate care 143 for the mother over the course of the prenatal and postpartum periods up to eighteen months. The comprehensive assessment is administered at intake, and per managed care guidelines, must be completed within 90 days of intake. This same assessment, in short form, is then administered trimesterly in the prenatal period, once postpartum within 90 days of delivery, and then once every three months until program end. Each time this assessment is administered, the Care Coordinator must update the ICP immediately for collective care management. Any number of Patient Rxs for Health can also be created to support the mother’s needs. All assessments plus PHQ-9 are to be entered into the “MAMA’S App” and will be migrated to ORCHID. Any printed ICPs and Patient Rx for Health must be submitted to Health Information Management (HIM, Medical Records) for scanning into ORCHID. This assessment is critical in determining a mother’s protective factors and strengths, psychosocial health issues, related internal or community-based services, and the intensity with which the team will follow-up with the client. Within the comprehensive assessment are a set of validated psychosocial scales embedded within the comprehensive assessment. Intensity of follow-up, however, is not based upon the severity of any one condition, but rather a combined score of all components of the comprehensive assessment. Therefore, a client who is homeless, substance using and depressed will require more intensive and frequent follow-up than a mother who presents with one issue, like depression. However, clinical latitude is allowed in this service model to encourage appropriate care treatment and support. These important care planning decisions are made by the multidisciplinary MAMA’S team and through Collaborative Care reviews. 144 Readiness-based Care Planning and the Activation of the ‘Neighborhood for Health’ Individualized Care Plans (ICP) are generated and updated in ORCHID after each serial assessment at minimum. To track and manage how each domain is addressed and tailor care to the mother, the ICP offers a summarized version of both the domain specific and Global Risk Score, readiness to address issues, areas chosen as first step goals and status of resource receipt. Paired with this is the Patient Rx for Health, which documents the community resources chosen by the mother in her neighborhood. The ICP fulfills compliance to CPSP guidelines, as well. On the backend, the ICP is linked to a resource directory that filters by neighborhood and risk domain. It is auto-populated with domain specific risk scores and basic patient information to start. Consequently, the Care Coordinator is able to offer referral resources to the mother in a tailored fashion, and in printed form on the Patient Rx for Health which is sourced from MAMA’S own resource directory, 211, Maternal Mental Health Now provider directory, and One Degree. Mentioned above, two important aspects of the ICP exist: 1) readiness to address domain specific issues, and, 2) need, choice and acquisition of resources that address problematic risk areas. The ICP incorporates an essential tenet of behavior change theory which purports the importance of acknowledging where a mother begins when she starts the journey of tackling problem areas. Readiness is also a fluid tenet aspect and usually parallels the level of trust a patient feels with her/his case manager, therapist and the like. As the relationship develops over time with the professional caregiver, the mother has the opportunity to self-examine, self-regulate, and find the strength to be vulnerable enough to face past issues and traumas that may be at the root of the behavior associated with the problematic risk domain. Care planning and the strength based, engaging and non-judgmental relationship necessary to enact care planning have been and will remain to be at the crux of the healing, growing and 145 activation of a mother. The concept of “compliance and adherence” can be better understood through review of the ICP and case review with the Care Coordinator. Health Education and Resiliency Building Prenatal Education and Resiliency Building Classes (PNER) class series is a critical piece of the MAMA’S care package in that it specifically using education, social support and promotion to build the self-efficacy of mothers accessing the program. Once two lines of service, it was merged after testing as a hybrid to reach more mothers in a way that was less stigmatized, more relatable and tailored to pregnancy. History Prior to 2013, DHS birthing hospitals ran their own class series of childbirth education. DHS WHPI leadership noticed a need to bring resiliency learning to its mothers as a means to reduce stress and improve pregnancy and birth outcomes. Thus, under the Strong Start Initiative – MAMA’S Neighborhood, it was charged with implementing these resiliency building classes with a cognitive behaviorally based curriculum previously tested in adult depression in low income racially and ethnically diverse regions of LA County. However, after two years of implementation, DHS WHPI noticed that engagement of mothers to a topic as nebulous and luxurious as “resilience” was not occurring. The author herein suggested that merging prenatal and childbirth education with resiliency building would yield higher numbers of engaged mothers. In March 2015, Department of Health Services Strong Start MAMA’S Neighborhood and Healthy African American Families (HAAF) launched two prenatal education and resiliency classes (PNER) at Harbor UCLA Medical Center. PNER classes featured two distinct curricula: prenatal education for expectant moms and coaches and resiliency building, all lasting 2.15 hours in duration. PNER classes were co-taught by MAMA’s Neighborhood health educator and staff 146 member from community partner, Healthy African American Families (HAAF) for a total of six sessions. The health educator covered a different prenatal topic each week, as did the HAAF staff member. An added feature of the PNER classes is the additional face time patients receive with a registered nurse. Up to 30 minutes per class is designated for the nurse to answer general questions, concerns and interpret lab work with patients. Patients participating in PNER classes can bring one coach or support person to each class (e.g. father of the baby, mother, sister, or friend). Added value is given to this support person’s presence as they not only learn prenatal content, but personally benefit from the coping skills provided through resiliency curriculum. PNER classes also emphasize patient advocacy as facilitators encourage and teach women skills to advocate for their health care rights within the clinic and well beyond the care provided to them at the Department of Health Services of Los Angeles County. Resiliency Curriculum: An Evidenced Based Approach The resiliency portion of the class originated from the Community Partners in Care (CPIC) and their collaborative partnerships with community and academic partners such as, Healthy African American Families, UCLA and the Rand Corporation. Together, these groups devised an evidence-based curriculum to reduce depression and low moods, tested in several populations. This curriculum was adapted and incorporated by MAMA’S Neighborhood with the hopes that the cognitive behavioral therapy offered through the resiliency curriculum could support self- awareness of low moods in expectant mothers and teach them strategies to combat low moods resulting from negative thoughts, anxiety and fear about the birth process, resulting in a less stressful pregnancy with positive birth outcomes. To date, the resiliency curriculum offered in 147 MAMA’S Neighborhood prenatal education is a dynamic facet of the woman centered approach to prenatal health care. Patient Informed Suggestions to Enhancing the Prenatal Education Program In August of 2017, more than two years into the continued teaching of prenatal/resiliency classes, MAMA’S Neighborhood has seen some pronounced changes to the prenatal education program. These changes have been largely shaped by the feedback provided by patients and coaches residing in the classes. Notable changes to the PNER curriculum are featured below in Table 4.6. 148 Table 4.6. Patient Feedback for PNER Class Structure Feedback Change Made Change Still in Effect? Not enough time given to evening class participants to drive from work to class or to get dinner before class. Push back the start of class from 5pm to 6pm ✓ Too much information covered in the postpartum section, felt overwhelmed, wanted to know more about birth control options Separated post-partum content for mom and baby into two separate sessions (now at 7 sessions). Birth control and pregnancy spacing taught alongside birth aftercare and postpartum depression. ✓ Desire to learn about alternative options to pain management in labor Added a class on comfort techniques, originally taught by a Doula (now at 8 classes) ✓ Not enough time to cover both curriculum content in 2 hours and 15 minutes Added an extra 15 minutes to class to give enough buffer to include breaks and account for prompt end time of classes (now at 2 hours and 30 minutes) ✓ Low class attendance when hosted in community academic setting (Charles Drew University) Moved class to outpatient clinic where patients already frequent to receive prenatal care ✓ Demand for Spanish classes Launched program’s first Spanish class in the fall of 2015 at Harbor UCLA Medical Center (LAC+USC followed in winter of 2015, Olive View followed in Spring 2017) ✓ RN extremely helpful in class Kept the RN in the structure of the PNER curriculum ✓ Current Structure of Classes The current structure, curriculum content and logistics of the class are the result of an iterative process driven mainly by each cohort of the PNER classes. Every cohort was given an opportunity to share feedback ultimately informing our program how to make classes more patient 149 centered and effective spaces for learning. Current structure of PNER is reflected below in Table 4.7. Table 4.7. Current Structure of PNER Classes Week Prenatal Topic Resiliency Topic 1 Welcome, introductions, class structure What is resiliency? What affects your mood and resilience? 2 Nutrition Pleasant activities to improve your mood 3 Exercise - prenatal yoga Harmful thoughts and how to change them 4 Breastfeeding Using support from others 5 Labor and delivery No resiliency due to hospital tour 6 Comfort techniques Practicing good communication 7 Postpartum care for mom Goal setting for me and my baby 8 Postpartum care for baby Celebrating your resiliency/graduation Expansion of Prenatal/Resiliency Education Classes Since the launch of classes in Spring of 2015, MAMA’S Neighborhood has currently expanded to a total of five sites, including Harbor UCLA (South Bay, SPA 8), LAC+USC (Metro, SPA 4) and Olive View Medical Center (San Gabriel Valley, SPA 2) (all DHS birthing hospitals), and MLK Outpatient Care Center, Hubert Humphrey Comprehensive Health Center (both in South LA, SPA 6), and High Desert Regional Health Center (Antelope Valley, SPA 1). MAMA’S Neighborhood currently holds 9 PNER classes across five sites in Los Angeles County, one third of those classes taught in Spanish. Classes are taught by health education assistants and health educators of MAMA’S Neighborhood. New Staffing Plan to Support Care Transformation To build the frame of this new standard of care delivery, decisions to broaden the staffing disciplines was necessary. A unique staffing structure was proposed to the County Board of Supervisors and CEO office that justified these items by linking them back to Managed Care 150 guidelines and the new CMS grant aforementioned (“Strong Start Initiative – for Mothers and Newborns). Included in this unique structure were 1) clinical site obstetric provider champion, 2) site lead nurse, 3) care coordinator 4) licensed clinical social worker, and 5) health educator. A maternal fetal medicine specialist, reproductive psychologist and reproductive psychiatrist were brought on as provider consultants to all sites to advise on design and provide planned expert medical advice for high-risk obstetric and psychiatric consultation. General descriptions of their planned scope are shown Table 4.8. below. 151 Table 4.8. Staffing Model Staff Position Main Role and Responsibilities Site OB Provider Champion (MD/NP/CNM) Public Health Pillar: Physical Health Role: “provider champion” Responsibilities: • On site provider (medical director or lead physician) • Models care that is collaborative, mother-centered, empathic and trauma informed, and evidenced based • Provides medical resident education on Lifecourse theory, Barker hypothesis, and impact of allostatic load of toxic stress on outcomes • Enacts guidance that accounts for her stressors and protective factors • Co-leads biweekly Collaborative Care all-staff meetings with the Site Nurse Lead and Care Coordinator that focus on risk- stratified case review and improving operational efficiency and effectiveness via rapid cyclical improvement discussions • Upholds that every clinic staff member, from front desk to nursing to discharge, is valuable in ensuring a positive patient experience and healthy unit-based team • References the patient’s Individualized Care Plan’s (ICP) at risk health domains in his/her visit with the mother, and elevates the Care Coordinator as a worthy resource in both anchoring her care and providing her community linked referrals • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well Site Nurse Lead (SNL) (RN, BSN, LVN in some circumstances) Public Health Pillar: Physical Health Role: “site nurse lead” Responsibilities: • Collaborates with all team members around their focus areas and facilitates the development and implementation of a comprehensive, interdisciplinary treatment plan focused on the ambulatory setting • References the patient’s Individualized Care Plan’s (ICP) at risk health domains in his/her visit with the mother, and elevates the Care Coordinator as a worthy resource in both anchoring her care and providing her community linked referrals • Oversees the coordination of care and communicates with patient, primary care provider, health care team and specialty care providers • Functionally supervises the Care Coordinator • Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family and patient education and identified healthcare needs • Focuses on each care episode in the context of the continuum of care for that patient and their unique needs • Focuses on a small percentage of high-risk/ high cost patients at a high level of service intensity with the provider champion and MFM and other required disease specialists. • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well • 152 Care Coordinator Public Health Pillar: Social Care Role: “mother’s anchor to care, support and wellness” Responsibilities: • Builds trust and rapport with mother • Understands the association between the success of care planning on quality of the relationship • Performs options counseling with topic specific sensitivity • Works closely with MAMA’S core unit-based team members: site nurse lead, provider champion, health educator and social worker/therapist • Performs psychosocial health assessments and generates Summary Sheet/Care Profile for all unit-based team members to refer to • Care manages according to risk stratification scoring, but use paraclinical judgement on mother’s needs should the risk score seem off • Develops individualized, comprehensive care plans tailored to patient’s readiness, needs, protective factors and abilities. • Develops a Rx for Health designating linked referrals and resources desired by mother’s/patient’s said goals • Proactively assists patients with navigating the medical, social service, behavioral health systems and Neighborhood partners to encourage a supportive and networked system of care • Provides approved patient education materials • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well Licensed Clinical Social Worker (LCSW) Public Health Pillar: Mental Health Role: “therapist” Responsibilities: • Provides clinical individual therapy and group cognitive behavioral therapy • Provides expert guidance on patients who present with severe and persistent mental illnesses • Provides expert guidance on care management prioritization and coordination to the Care Coordinator • Works closely with MAMA’S core unit-based team members: site nurse lead, provider champion, health educator and Care Coordinator • Provides approved patient education materials • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit based team to do so, as well Health Educator (HE): Public Health Pillar: Role: “health educator” “neighborhood liaison” Responsibilities: • Coordinates all aspects of health education and promotion 153 Health Literacy, Social Support, Education and Resiliency • Recruits mothers to and conducts prenatal education and resiliency building class series • Conducts narrowly casted education and promotion campaigns to raise awareness of a topic • Spearheads all on site collateral materials replenishment and management to ensure racial, ethnic and linguistic awareness • Assists in partnership building in the Neighborhood • Partakes in evaluation activities to measure impact of their work, and in Collaborative Care meetings locally at their assigned site(s) • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well Reproductive Psychiatrist (MD) Public Health Pillar: Mental Health Role: “reproductive psychiatrist” “mental health redesign-er” Responsibilities: • Clinically manages all severe and persistent mental ill mothers • Liaises with obstetricians on prescription medicines and medication management • Redesigns mental health pathways to care within site and countywide • Provides expert consultation to all unit-based team members in accordance with licensure • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well Women’s Health Psychologist (PhD) Public Health Pillar: Mental Health Role: “mental health redesign-er” Responsibilities: • Assists in the redesigning of mental health care pathways for women’s health • Participates in Collaborative Care meetings and care planning • Liaises with unit-based team • Provides expert clinical consultation on modalities of therapy needed for therapists • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well 154 Maternal Fetal Medicine Specialist (MFM) (MD) Public Health Pillar: High-risk Medicine Role: “perinatal specialist” Responsibilities: • Provides expert clinical medical consultation for high-risk, complex multi-morbid medical mothers • Participates in clinical review team meetings regarding necessary care planning • Advocates for and provides expert consultation for interconception care planning • Drafts expected clinical practice guidelines for obstetricians at DHS clinical sites • Provides letters of support for mothers needing assistance in their DCFS cases, if appropriate • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well 155 Phase 3: Maintaining the Infrastructure for Organizational Change Overview In reviewing infrastructure needs to sustain the organizational change within a healthcare (Key Driver 1: Seek, Select and Customize the Best Evidence for Use by the Practice; Key Driver 4: Create and Support High Functioning Care Teams to Deliver High Quality EVB Care; and Key Driver 5: Engage with Patients & Families in EVB Care and QI). Two drivers were met, “somewhat” including: Key Driver 3: Optimize Health Information Systems to Extract Data and Support Use of Evidence in Practice; and Key Driver 6: Nurture Leadership and Create a Culture of Continuous Learning and EVB practice). One driver was unable to be met at the time of change (Key Driver 2: Implement a Data Driven Quality Improvement (QI) Process to Integrate Evidence into Practice Procedures). These comparisons can be seen in Table 4.9. 156 Table 4.9. AHRQ EvidenceNOW Key Drivers for Organizational Change Comparison (AHRQ, accessed 2020) AIM KEY DRIVERS CHANGE STRATEGIES DHS INFRASTRUCTURE BUILT ASPECTS OF CHANGE MET GAPS IN THE ASPECTS OF CHANGE Improve health care quality by increasing the capacity of primary care practices to implement the best clinical evidence Key Driver 1: Seek, Select and Customize the Best Evidence for Use by the Practice ▪ Develop a process to search for new evidence ▪ Select and customize evidence for practice wide implementation ▪ Embed selected evidence and guidelines into clinical info systems ▪ Inform pts and families about the evidence the practice uses and its implications ➢ New perinatal clinical practice guidelines ➢ New care model built into EHR ➢ New program is shared with mothers when they enroll and throughout ➢ New model was tested at 5 sites before scaling ✓ - This is the most developed currently. Key Driver 2: Implement a Data Driven Quality Improvement (QI) Process to Integrate Evidence into Practice Procedures ▪ Develop an inter- professional QI team that meets regularly ▪ Adopt a consistent QI approach and use QI tools to make changes ▪ Select internal QI measures, collect data, compare with goals and benchmarks and act on data regularly ▪ Engage care teams and other staff to support implementation of new evidence At the start of the MAMA’S program, QI was in its plan. Due to lack of readiness, QI team and processes were not implemented. No - No team - No agreed metrics - No process - No site knowledge of how to adopt CQI culture 157 Key Driver 3: Optimize Health Information Systems to Extract Data and Support Use of Evidence in Practice ▪ Identify & train a Data Coordinator ▪ Use EHR to improve data collection ▪ Use registries and other data sources creatively to track the provision of EVB care ▪ Involve care teams in refining documentation workflows to minimize burden ▪ Improve data accuracy and transparency and secure staff trust ▪ Link patients to their clinicians and teams within the info systems to improve usefulness of performance reports ▪ Create dashboard reports for selected measures ➢ Data Director on board ➢ Data team on board ➢ EHR launched, documentation has been migrated ➢ EHR has new model integrated, although not complete or exact ➢ EHR is used in reporting and for quasi-QI implementation modifications ➢ Multilevel teams are used to critique workflow ✓ Somewhat - Parts of the assessment and linkage to referrals model is lacking in current EHR system - A dashboard is being drafted Key Driver 4: Create and Support High Functioning Care Teams to Deliver High Quality EVB Care ▪ Establish care teams & delineated roles for clinical and non clinical staff ▪ Assign pts to clinicians and teams to create accountability and a sense of shared responsibility among the team for their pt panel ▪ Empower team members to have authority and skills to do the job ▪ Optimize care team communication ▪ Support care team learning about new evidence ➢ Unit based teams have been designed ➢ Patients are empaneled to both clinical and care coordination staff ➢ Continuous learning and training is provided to staff ➢ Communication is supported through huddles, Collaborative Care chart reviews, clinical operations team meeting, leadership meetings, ✓ Mostly - QI is not fully implemented to its EVB model - Staff is not trained in this methodology, but quasi sense of continuous review and adaptation is evident 158 ▪ Make reviewing their performance and participating in QI activities part of everyone’s roles and responsibilities disciplines-based meetings ➢ New evidence is brought forth through TTA and decentralized team channels ➢ QI is a part of staff duties, however, not performed per model Key Driver 5: Engage with Patients & Families in EVB Care and QI ▪ Establish workflows that identify and engage pts affected by changing evidence ▪ Support pt and family engagement in their own EVB care ▪ Link pts and families with community resources to assist them in implementing EVB care plans and meeting their health goals ▪ Involve pts and families in moving evidence into practice ➢ Patients are linked to resources needed via ICP and Rx for Health ➢ Readiness to change is discussed during the assessments, as a basis for implementing EVB behaviors ➢ Workflows are reflective of patient first priorities ✓ - This is the most developed driver at this time. Key Driver 6: Nurture Leadership and Create a Culture of Continuous Learning and EVB practice ▪ Forge a vision of adapting to new evidence ▪ Provide organizational and leadership support for EVB practice and QI ▪ Encourage learning about new evidence and best practices ▪ Review measures of implementation and ➢ A culture of continuous learning is integrated ➢ Measures for EVB practices in clinical context occurs regularly ✓ Somewhat - A chartered commitment for QI is needed 159 impact of EVB practices regularly ▪ Identify and support champions for learning, EVB practice and QI within the practice ➢ Create a culture in which all practice members feel comfortable identifying opportunities for QI 160 Phase III Summary Building in infrastructure to sustain organizational change is just as hard as beginning the changes themselves. Through this comparison of supports that may assist change in healthcare settings and clinical planning meetings, elements to assist change were implemented. DHS found supports integrated in tandem are necessary to sustain change. Additional steps to integrate continuous quality improvement formally with a designated team and review structure, along with process and outcome metrics will assist in each site’s motivation to maintain fidelity to the new model of perinatal care. Chapter 4 Summary Major investments were made during this feasibility analysis that included: making the case for change; assessing readiness, building the infrastructure needed to support the change; defining and refining the innovative, new components of perinatal care; training on the new roles and responsibilities of staff, components and workflow; and integration of infrastructural supports to sustain the change. At the executive level, necessary and frequent planning discussions were held to rapidly and cyclically test and retest the quality improvement change, and to continue to prioritize the narrative among those C-suite leaders and to manage competing systemic external forces. As a result of this inquiry, these analyses were used to inform the development of MAMA’S Neighborhood framework and implementation manual which is this study’s contribution to practice. Three phases were of organizational change and its products within emerged, including: 1) Laying the Groundwork consisting of the development of the MAMA’S Neighborhood Driver Diagram, Collaborative Service Model, and Levels and Tenets of Mother 161 Engagement; 2) Building the House for Organizational Change consisting of clinical level service enhancements included: a) systematized and summarized SDOH/SCTH 15 (social determinants of health/social contributors to health) psychosocial assessments and risk factors electronically available to all members of the care team, especially clinicians, b) Collaborative Care chart review and multidisciplinary huddling; c) readiness based and individualized care planning, risk algorithm for care intensity stratification and follow up; and d) a hybridized perinatal educational support model focused on building practical maternal knowledge and skills concurrently with resiliency and self-efficacy, e) community partnership matrix to build the Neighborhood Network of Care; f) new staffing plan to support the changes in service delivery, especially the additional investment of Care Coordinators to anchor care and track and monitor mothers’ SDOH/SCTH, e) a parental and baby ‘boutique’ of basic needs essentials redistributed from donors to enrolled families to attend to social care needs; and 3) Maintaining Organizational Change consisting of discipline specific meetings, clinical huddles, Collaborative Care meetings to review care profiles, risk stratified care reviews among multidisciplinary group of program leadership, EHR integration of 15 Social Determinants of Health (SDOH) and Social Contributors to Health (SCTH). I offer here another perspective on the popularized term ‘determinants.’ In marginalized communities, to have systemized structures put upon many has negatively determined many people’s futures. Second, in marginalized communities, it is commonly felt that within a racial or ethnic group there is already power within, so being ‘empowered’ by another is again, top- down, white tower mentality. Rather, power that has been held tight among the few at the top, needs to be relinquished and redirected back to those marginalized communities, so that the space is there for them to rise up, breathe, thrive, and own their own destinies. To have the literature reflect the social issues that have ‘determined’ negative health outcomes is again a top-down, white tower way of looking at the construct of society, its factors within and what they produce. Statistically speaking, to have a factor ‘determine’ an outcome as in it being causally related, it must have enormous statistical power, careful randomization, and rigorous and representative sampling. The literature does not reflect now that social issues are alone causally related, but rather they are contributory factors to health outcomes. Being a ‘contributing’ factor honors that multiple systemic barriers and flaws exist, and that a local social issue such as unemployment or unaffordable housing, or under-resourced schools, are not alone in fixing the problems associated with poor health outcomes. It presses on the system to reflect intentionally on what it is, how it is perceived, where it wants to go and what it wants to be. As well, many marginalized communities document that the system ‘determining’ their fate or health outcome is again, top-down, and many groups strive to fight against historically racist systemic structures that have oppressed them and continue to oppress them. In close, changing terminology and the intent of words or the narrative are mandatory steps to social justice, changing policies and how systems associated deliver care – essentially, for this paper, it is essential for reproductive justice. Words and phrases matter. 162 the model components (mostly), physician champions, Site Nurse Lead champions, and regular data quality assurance processes. Resultant from this contribution to practice were changes in countywide institutional policies, program level philosophy and guiding tenets, and clinic level operations to be more mother centered. Adoption of MAMA’S Neighborhood as the new standard of care enterprise wide was achieved. 163 Chapter 5 Recommendations and Conclusions Study Discussion As seen in this document, improving birth outcomes requires dual action of the healthcare system “unfreezing” itself to defragment, and reorganizing and re-ranking its values; simultaneously, it requires mothers being able to trust a more humanistic, tailored model of care (Hussain, et al, 2016). Systems and organizational change require a multidisciplinary approach with involvement from unassuming actors and influencers. To truly reflect and ground change for the community’s benefit, community’s voice must be and stay involved from start to finish – it is not a ‘father knows best’ mentality anymore where paternalism succeeds over society’s needed improvements, and especially when maternity care is just that – maternal. DHS made the brave leap to address the core wicked issues ailing its maternity system of care by developing and implementing MAMA’S Neighborhood. As with most renovations, all change can’t happen at once, and maybe for the betterment of sustainability. One way to view MAMA’S Neighborhood change wheel is to see it through the lens of three wheels of concurrent change processes. Simultaneously, to change, DHS needed to “reflect, repair, and release” old processes; to endure “reorganization and refinement”, and then; keep itself grounded in its changed commitment to “relationships, resilience and readiness.” As in phases that include a time zero, then phases 1-5. Below is a snapshot of the organizational changes and its possible next steps in that change arc – after all, growth, adaptation/resiliency and readiness are elements of survival. 164 Figure 5.1. DHS Women’s Health Services Change Wheel Reorg, Refinement Reflect, Repair, Release Resilience, Relationships, Readiness 165 Evident from this analysis, managing this organizational change took a stepwise process. First, establishing the will and a shared conceptual model for mother-centered care among executive leadership was a must. Without this, changes would not have launched, unless major social upsets were to have catapulted the demanded changes into action (e.g. social and political unrest). Second, a collaborative governance model of decision making was employed to garner assets and drawbacks with all levels of staff through the Stages of (organizational) Change. It was the second stage of building the will to change. Third, while on that path of change, the Model for Improvement was harnessed as a mechanism to do mini-digestible tests with staff. This built a team mentality towards change, displayed the outcomes quickly of their suggested changes, and again, built the will for improvement – together. Last, and again decided in a collaborative fashion, infrastructural supports were put in place to sustain the changes. To exemplify this growth, two paradigm shifts, and four critical pathways emerged as salient to DHS’ capacity and resiliency to change (organizational [self] efficacy). These include: Paradigm Shifts 1) Ensure mothers” capacities and resiliencies stay at the center of care and all care change decisions 2) Evolve from ME to WE at every level of service delivery: care planning among providers, care prioritization with mother, administrative operations and evaluation. 166 Critical Pathways: 1) Ensure the values of the identified change are clear and agreed upon by consensus at the executive levels extending to (not down to) frontline levels using principles of collaborative governance, participatory inclusiveness and appreciative inquiry; 2) Utilize an evidence based, data driven and participatory model grounded in health behavior change theory and ecological theory to base the organizational change in, including methods of how to assess and make those changes from start to maintenance; 3) Invest in managing oppressive external forces of the system that frame and influence the organizational change, and feeding back regularly the victories and valleys of doing so to frontline staff; and, 4) Prioritize highly the basis for systems and organizational change not only on outcomes data, but on the mother’s levels of trust and satisfaction, degree of engagement, level of readiness to change, and current and influential and pervasive societal contextual factors. Through this arc of change, DHS was able to adopt a new model of mother centered care enterprise wide, and achieve monumental improvements to perinatal care. Seen as a phase I of change, still many improvements are needed to enact its model and keep its fidelity to enter a new phase. Phase II in its arc of change could include strategies of integrating improvements to reflective practice, health equity, trauma informed care, maternal autonomy, consumer involvement in care modelling, clinician expected practices, and the like. A Maternity Centered Medical Home model of care may be a viable option for other large, complex Medicaid-based systems to consider that have competing cost demands but who desire to be more progressive and inclusive/collaborative as defined as: more care that is precise, risk- 167 stratified, comprehensive, coordinated, compassionate and culturally/racially attentive, and which by design, strive to prioritize trusted, leveled patient-provider relationships based in shared decision making, maternal autonomy and assets and behavior change theory, tailored connections and care pathways that match mothers’ unique lives and lifestyles, and does not judge, accepts and meets mothers where they begin. The challenge for complex systems remains to be the maintenance of fervent and authentic model fidelity even in times of financial pressure, changes in leadership, and fluctuations in the ecosystem created between mother and system. The key is balance – to use technology (not overmedicalize) when necessary, and, prioritize and praise human connection, relationships and heartfelt care coordination as huge value added traits within an institution’s human resources and thus, worth the investment, both for brand loyalty and cost savings. Building trust with patients in healthcare is the single most important driver of an individual’s motivation to change and health status improvements. Without this connection, a healthy relationship cannot be built or maintained such that health improvement can be supported. Modeling the caring it takes to address adversities or celebrate the joys during and after pregnancy is critical in laying the foundation for the mother to care about herself and her newborn. Showing her that she is worth that careful attention and care not only builds trust, but builds her self-efficacy to be a present, informed mother. Especially in marginalized racial and ethnic groups, trust in the provider’s brand is the predecessor to engagement from the start of choosing a provider, and then, it becomes paramount in laying the foundation for a healthy patient-provider relationship that supports addressing the hardest, deeply rooted adversities that may be “weathering” on her health, and negatively setting her up for a preterm birth or even maternal death. 168 Physicians/midwives don’t need to be the sole supporter and change agent. Empathic, mother-centered care requires medical providers to reflect on their role to be one agent of change ready to courageously engage the pregnant mother heart-to-heart, and change the systems that don’t put the mother first. It is the conscious leadership of the medical provider that creates a visibly inclusive, leveled and multidisciplinary team which then gets activated to provide the psychosocial care services they are trained to do. Those nurses, therapists and care coordinators are team that will address the social determinants/contributors of health weighing on the pregnant mother. And, moving out of her way and supporting or linking her to care she trusts in her community is the job of that psychosocial team. It also requires systems to “unfreeze” (Hussain, et al, 2016) its policies and practices, allow the space for reorganization with mother front of mind, test these proposed changes rapidly, and make the needed adjustments. Staying in an adaptable state is hard, and sometimes more stability is needed; but, with champions for change in leadership to be the safety net of their unit based team’s agility will provide the security staff needs to keep a nimble state of mind and service provision. It is human nature to want concrete, routinized processes so that a constant state of stress is not felt. Thus, ensuring that the organization’s/unit-based team’s champion has the circumspect to balance adaptation with routinization is critical. As with a human body, the organization/unit-based team is its own ecosystem with hubs and users of energy to keep in homeostasis. Medicine must keep up with the new more ecological and humanistic era of collaborative thinking, shared decision making and a leveled playing field. No longer is a top- down approach to care desired or accepted as normal in healthcare settings. Without a relationship focused on trust with a pregnant mother, engagement in care is poor, and intervention is unlikely and repeating poor outcomes is more likely. Providing care is just that 169 – care that gives something of need to the recipient that is seen as valued and delivered in a way that is relatable, tailored and empathic. An investment of time to build trust and a relationship of value can yield the opportunities for precision care management. It is simple – women will seek services when they find value in the care they are accessing; when they are authentically respected, engaged in decision making, not judged, and supported; and when care is tailored to her needs first. After these attributes are met, care on other levels and higher risk can be explored. It is Maslow’s Hierarchy of Needs translated through a patient engagement lens – basic needs first, then higher order of self-improvement second, and so forth. 170 Recommendations Seven recommendations are made for the LA County Department of Health Services, Women’s Health Programs and Innovations unit to consider as steps are made to further refine how it retains Medicaid mothers to care from prenatal to interconception, pointedly reaches out to African American/Black mothers, clinically manages multi-morbid mothers while pregnant and interconception, strengthens its community connections, and values Social Care as much as Medical and Mental Care. Recommendations are mentioned here to guide a thoughtful next phase of improvement to the model of maternity care at LACDHS. Recommendation 1: Invest in Clinical Care Quality Improvement A) Invest in Care Quality Improvement coaching with clinical and regionally based teams. Re-establish each team’s champion for change, and fill gaps where they exist with additional consulting staff who will be more present to troubleshoot dashboard metric reviews and change management tactics. B) Institute a clear algorithm for precision care management that maintains the principles of flexibility and accessibility. This model is efficiency and consumer minded such that it fluidly adapts what is needed where, by whom and at what time. What current home visiting models do now is mostly prescriptive with one type of care provider. The MAMA’S Neighborhood model utilizes three different care providers (public health nurses, social work therapists and community health workers) to address different aspects of antenatal and postnatal, as needed. Although this fluidity is difficult at times, an intervention (program activities) schedule provides a framework to what issues, education and assessments are needed when and to what risk level. For precision care management 171 to work in this dynamic model, an investment in building and maintaining strong multidisciplinary care teams should occur. Continuing to train staff to be collaborative thinkers and operators is critical to a nimble model, because decisions are made to be responsive to mothers, not follow a textbook. Balancing evidence-based practices with organic needs of the mother is the art of collaborative care, and therein, precision management. To minimize risks inherent with becoming too tailored with precision care, within these collaborative care structures, checks and balances of priorities and decisions that maintain the centralized focus on the mother can and should be leveraged and audited by, at the very least, internal design or evaluation personnel. C) Review the following documents and crosswalk principles with MAMA’S Neighborhood to further refine its model and implementation towards a mother centered care design and one that is of highest value. o 2020 Vision for Maternity Care o Blueprint for maternity care o Mother Friendly Childbirth Initiative o National Fatherhood Initiative (to promote family inclusion, infant development, and social support structures shown to be contributory to strengthening families and next generations) D) Consider lowering the case load of Home Visits Care Coordinators to be no more than 13- 26 mothers to reflect what intensive home visitation literature recommends. Analyze case loads for ‘changed’ or ‘undivulged’ risk levels, and create a Tiered Care Management Model that redefines the high intensity of the model, proper division of labor and priority concerns to the appropriate primary professional, and delineates different levels of ability 172 to serve, i.e. high intensity vs. ‘MAMA’S minimum trimesterly package/menu of care’. Care Coordinators are the foundational force that begins positive relationship building with mom and her Collaborative Care team can assist in determining who is primary in care giving when and how much as the relationship and care giving unfold (helps with precision). An investment in further specifying and tailoring their skills to include lactation education, childbirthing, motherhood adjustment from a psychological perspective, grief and loss, and resiliency building using cognitive behavior methods could allow for better relationships to be built. E) As mentioned in the background of this document, the interconception period is critical for continued management of mood, chronic disease, social support, social network, infections, family planning, violence exposure and other economic and social care toxic producing stressors. Drafting an evidence-based and/or evidence informed interconception care service package to guide services during this period would assist both staff and mothers to feel more empowered and cared for, respectively. It is highly recommended to pair this service package with: a) an individualized care plan tool that is framed with a social support/network/capital lenses and noted protective factors/assets (builds resiliency, self-efficacy, resourcefulness, community connections, and hope); and, b) a dashboard of interconception metrics that can be monitored monthly for care quality improvement using the Breakthrough Series methodology. 173 Recommendation 2: Invest in Training and Ongoing Capacity Building A) Draft a reproductive health equity curriculum for medical residents and nurses, and test at one birthing hospital prior to scaling. Implement accountability measures vis a vis patient satisfaction that is captured before postpartum discharge. B) Likewise, use this curriculum to train up all medical and jail staff at Central Regional Detention Facility (CRDF) women’s jail where many pregnant women are detained, and where an inordinate amount of single, low income, survivors of violence and trauma (Swavola, E, et al, 2016). Accompany this care with Doulas who would be assigned to the jail and be present at an incarcerated mother’s birth. As well, this Doula would conduct psychosocial non-medical support to the mother during her postpartum time while in jail. Other responsibilities would include connections to family, DCFS and the infant placement, breastfeeding/pumping support and milk retrieval by family, and bridged support during her re-entry process. C) Train Home Visits Care Coordinators to be Full Spectrum Doulas to address racial disparities in delivery methods and low mother retention at birth of those enrolled in MAMA’S Neighborhood. Record birth stories, experiences and satisfaction with care, breastfeeding uptake and duration, mood regulation, mother-baby attachment, as well as, outcome of maternal mortality/life and infant mortality/life rates. Recommendation 3: Offer Compassionate Care to Women with Complex Histories A) Draft a Race Equity Framework for MAMA’S Neighborhood a. Implement a brave health equity framework (strategy and logic model) based in Critical Race Theory and Praxis within MAMA’S Neighborhood that highlights 174 specialized programming specifically for African American and Black mothers. Investigate the utility of the R4P model designed by Dr. Vijaya Hogan and colleagues (Hogan, V. et al, 2018) that incorporates Critical Race Theory and intersectionality with dimensions of time to improve health outcomes. This model outlines a framework that structures programming with checks and balances against essential tenets that aim to reduce structural racism that may be linear and non- linear in nature and context of perinatal care (check against model). The four Rs and P include: (1) Remove, (2) Repair, (3) Remediate, (4) Restructure and (5) Provide. Racism, classism and sexism and how they interface with service delivery is the focus of the “provide” in R4P, with recommendations of qualitative inquiry to support this component so as to contextualize what program staffing may be experiencing, mothers in the program may be thinking, feeling, experiencing and taking home and enduring in their communities, and what is thus, needed to not leave mothers left alone to sort out the stress exerted from the health system. b. Pilot creative ways to support mothers by offering programming that is designed by them, for them, and co-led by them. c. Draft a pilot accountability plan for all providers that addresses racism in the delivery of perinatal care. B) Draft a Trauma Informed Care framework to overlay upon a care model that is precise, racially mindful and equitable, relationship based and socially supportive. Trauma Informed Care is a “perspective through which an organization realizes the impact of trauma on its families, recognizes the signs of trauma, and uses that understanding to improve client engagement, outcomes, and organizational services” (Menschner & Maul, 175 2016; SAMHSA, 2014). Intergenerational transmission of trauma can contribute to the alleviation through precise, mother centered home visiting by first building the healthy attachment with the MAMA’S care giver, and then encouraging the healthy attachments with baby. “A safe environment and nurturing relationships are two important protective factors in a child’s life that can foster resilience and help to outweigh the long-term effects of trauma” (Cairone, et al, 2017; AAP, 2014; CDC, 2016). Building that secure attachment between mother and baby is a critical component linked with child’s social and emotional outcomes. Attachment is defined by “one specific and circumscribed aspect of the relationship between a child and caregiver that is involved with making the child safe, secure and protected (Bowlby, 1982; Ainsworth, 1978). Benoit describes the difference in attachment vs. a bond by: “the purpose of attachment is not to play with or entertain the child (this would be the role of the parent as a playmate), feed the child (this would be the role of the parent as a caregiver), set limits for the child (this would be the role of the parent as a disciplinarian) or teach the child new skills (this would be the role of the parent as a teacher). Attachment is where the child uses the primary caregiver as a secure base from which to explore and, when necessary, as a haven of safety and a source of comfort (Water, et al, 2000). “A trauma-informed approach can also help prevent burnout and turnover among home visiting program staff, which ultimately impacts retention, success, and well- being among the families served” (Cairone, et al, 2017). Home visiting can play an important role in alleviating the intergenerational transmission of trauma by helping parents and caregivers build positive and healthy attachments with their children. 176 Drafting a plan that is psychologically and psychiatrically sound that focuses on supporting a healthy secure attachment can be important in a care model design that is Trauma Informed. Types of attachment and their antecedents are noted here in the table below as a reference and would be used by qualified professionals in designing the Trauma Informed framework that would support postpartum/interconception care activities. Further explanation is needed to better expand each column header: quality of care giving, strategy to deal with distress and type of attachment. Research strategies can be bold in piloting these evidence informed strategies to reduce stress and address her stressors (such as violence and past traumas) in the prenatal mother and immediately postpartum and up to 18 months. Investing in the mother’s health during this time will assist in bolstering her capacities and resiliencies to improve her overall health and wellbeing over the lifespan and be an improved model of health and wellbeing to her child. Choose, integrate and promote maternal metrics that will demonstrate improved health and wellbeing, while keeping generational outcomes in mind. Flip the driver diagram to have maternal metrics as the end outcome instead of birth outcomes and child related health outcomes. Although the best birth outcomes are critical for the betterment of a next generation and society at large, deleting programming and indicators that measure a mom’s health increases the likelihood of recurrence of these poor birth outcomes because the original host is not being addressed – mom. As the infant matures, she/he is still linked to that mother and father figures over a lifespan, and a Quality of caregiving Strategy to deal with distress Type of attachment Sensitive Loving → Organized → Secure Insensitive Rejecting → Organized → Insecure-avoidant Insensitive Inconsistent → Organized → Insecure-resistant Atypical Atypical → Disorganized → Insecure- disorganized 177 true Lifecourse model would augment, elevate this as a priority investment. By doing this, programming can address racism in the system more fully because the end outcome is flipped and the spotlight of change is on what the mother is experiencing, thinking, feeling, enduring and ending up with. These could include: maternal depression, maternal anxiety, built social network, experience of racism in care, mood, resourcefulness, chronic diseases, social connectedness, general sense of stability [perhaps a metric instead of being housed and having access to food]. The idea is to not make improvement of health solely focus on whether the baby is healthy, adjusted, and ready for school – it is to acknowledge and accept that many mothers have not reconciled past traumas and that supporting that change will have longer term effects than gauging health just on the child (who is being raised by a mother and father/partner/family that has not yet worked out their challenging histories). Focus on recovery and maternal autonomy rather than the disease when attending to substance use disorder/exposure including opioids, intimate partner violence, and psychiatric illnesses is recommended by the NCQA for a PCMH and researchers in the field (SAMSHA, HRSA, 2014). The use of opioids has dramatically increased over the last decade, and both mothers and their newborns are suffering as a result, with many of those pregnancies leading to preterm births. As well, from a maternal mortality perspective, maternal suicide is included in its definition according to California Maternal Quality Care Collaborative (CMQCC) and other national organizations. Preventing this growing statistic is possible with proper screening, treatment integration of services in clinic and at home, and engagement of mother to ‘establish the win’ for her in taking steps toward wellness, stability and functionality. Autonomy in decision making for those who live with addiction is critical piece of this model – taking away control of decision making and agency pushes patients (mothers) away. Use a consultant to draft what 178 integrated care would look like and that accounts for common stigmas, engagement issues (recruitment, retention, relapse, infant removal, co-parenting), and stage of change. Sometimes being well is a foreign concept to those with deep trauma, and the return to a dependent, chaotic state or life is more comfortable than being well. Or, sometimes adverse mood states with certain psychiatric illnesses, like bipolar I, yield more creativity in their lives. Making care about the person, not the compliance to treatment, is the common theme of improving health outcomes. Understanding mothers’ perspectives, their win (knowledge, attitudes and behaviors) as they seek care, and dually holding the space for evidence based medicine as well as mother centered care will yield a better chance of stronger health for mom and a healthier start for baby. Recommendation 4: Expand Care to be more Holistic by Including Fathers/Partners Draft and implement a robust mother and father engagement plan to include these three objectives: 1) Health Promotion: develop a mother mentorship committee to be ambassadors of MAMA’S to frame Healthy Start Community Action Network discussions with a collection of birth stories and waiting room health promotion 2) Father Engagement: draft a plan and logic model to engage fathers that is evidence based and mindful of race and equity challenges. Hire fatherhood specialists to implement this plan with building the neighborhood network of care in mind. 3) Postpartum Education and Resiliency building Activities: execute “socials”/”house parties” as ways of healthy promotion and education. During these gatherings, mothers and/or partners together and alone would aim to build social support, transition into motherhood/parenthood more smoothly, and support a healthy secure attachment between 179 mom and baby. Add a resiliency based co-parenting class series to frame father involvement in mother-baby life. Recommendation 5: Explore Financing Interconception Care up to 18 Months Currently, California is up for reallocation of its 1115 Waiver monies that allow for tailored implementation of Medicaid dollars in health care services. Design teams are meeting now to devise a plan for the State. It would behoove DHS WHPI leadership to advocate now for 1115 Waiver dollars to pilot a tiered level of insurance coverage extension to 18 months postpartum for those multiparous women with a previous preterm birth, primiparous women living under 200% of poverty, and any African American and Black pregnant woman. It could also take the form of a bundled payment option under insurance plans as it is implemented. Opportunities for Future Research & Activities Many aspects of care could be explored when examining the usefulness of a care model. In this context, areas to consider could begin at: ✓ Evaluate the improvement of mood symptoms and efficacy in the PNER classes as a model for other program activities that do not focus on resiliency and social support building. ✓ Pilot test Doulas for black mothers at 1-2 birthing hospitals at DHS as a means to improve support during labor and delivery, transition into postpartum and motherhood adjustment. Outcomes could be lowered C-section rates, higher patient satisfaction during delivery, higher breastfeeding uptake and duration, lower use of augmentation during delivery, decreased depressive and anxious symptoms, higher self-efficacy, improved social support network 180 ✓ Further systematic collecting of mothers’ voices, compiling them for mutual review and continual integration into program enhancements are recommended to adhere to a community partnered participatory program whereby mothers’ take an active role to a) assist in steering activities, b) provide nuanced understandings of services designed; so as to move from designing for them to designed by them; c) providing program implementation training to support future economic empowerment; and d) and to always keep the medical, academic, and grant related work tethered to realities experienced in the served communities. ✓ Create and implement a dashboard of quality improvement metrics (population/program and patient level) that assist in achieving desired end outcomes supported by an enhanced logic model for MAMA’S Neighborhood. ✓ Develop a strategic plan that is both macro for the MAMA’S Neighborhood program at- large and micro that delineates substantive objectives with measurable tasks. ✓ Create a “MAMA’S Oath” that is developed by staff and is posted to cue staff to important values of the program. ✓ Outsource a return on investment of MAMA’S Neighborhood to inform health care system policies and allocations. ✓ Compile and/or create a MAMA’S Toolbox that contains all trainings, emerging methods and research and suggested readings to improve content knowledge or job performance. 181 Conclusion Although enormously challenging, integrating a multidisciplinary, coordinated and community-inclusive model of perinatal care as a Maternity Centered Medical Home is feasible, and can be collaboratively generated within a complex bureaucracy if leadership has bought in to the change, quality improvement coaches/staff are designated, and models of improvement, mother’s autonomy, and community engagement are adhered to. Overlaid with this are important racial and cultural nuances in the Black experience that must be independently named so that the parallel reflections and growth in health systems and practitioners can occur. With this reflection, humility, authentic consistent inquiry and “showing and following up”, trust can begin and health care systems can do their part to help undo what has contributed to Black mothers’ egregious adverse maternal and infant outcomes. Transmuting this analysis’ recommendations into actionable steps will be important as the system further enhances and expands its care to meet mothers where they begin. 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Contribution to Practice 200 Los Angeles County Department of Health Services Women’s Health Programs and Innovation Maternity-Centered Medical Home Implementation Manual, Version 2.0 Fall, 2017 201 Table of Contents Sections Pages [excerpted from original] 1- History 2- Design 3- Rationale 4- Conceptual Model 5- The Concept of a Medical Home 6- Staffing Model 7- Risk Stratification and Comprehensive Assessment 8- Individualized Care Plan 9- Care Management 10- Prenatal Education and Resiliency Building 11- Change Package 12- Care Model for Perinatal Health 13- The Model for Improvement 14- Appendices Appendix A: PDSA Cycle Test Sheet Appendix B: MCMH Effective Team Meetings Appendix C: Process for Beginning and Maintaining Relationship Based Care Appendix D: Summary Individualized Care Plan 202 Appendix E: Sample Algorithm for Social Care Rx for Health Appendix F: Self-Management Support to Establish Readiness 5 A’s of Self-Management Confidence of Selected Goal Scale Addressing Barriers and Writing SMART Goals Figure 1: MAMA’S Neighborhood Care Team Figure 2: Multisystem Construct of MAMA’S Neighborhood: How We Work Figure 3: Driver Diagram Figure 4: Model of Mother Centered Care Figure 5: New Clinical Care Workflow Figure 6: Schedule of Care Planning and Coordination Figure 7: Care Model for Perinatal Health Figure 8: Model for Improvement Table 1: MCMH Care Commitments Table 2: MCMH Care Transformation Staffing Model Table 3: Patient Feedback for PNER Class Structure Table 4: Current Structure of PNER Classes Table 5: Change Package 203 1. History A new department established in 2011 at the Los Angeles County Department of Health Services (DHS), the Women’s Health Programs and Innovation, was developed to organize and improve primary, secondary and tertiary women’s health service delivery over the Lifecourse with the lens of community based decentralized medicine, prevention and mother- centeredness. Previous efforts predating department creation addressed women’s health from an urgent emergent medicalized perspective, hierarchically and without culture or race/ethnicity in mind. Under the direction of Erin Saleeby, MD, MPH, and an end goal of the reduction of preterm birth and low birthweight, this department drafted a strategic plan called, “MAMA’S Neighborhood,” an acronym standing for: Maternity Assessment, Management, Access, and Service synergy throughout the Neighborhood for health. This plan included three innovation aims that would support the transition of perinatal health services into Maternity Centered Medical Homes: i) Clinic operational efficacy to competently and confidently serve diverse women within a collaborative, unit-based team framework with: a. Risk appropriate levels of care; b. Tiered staffing infrastructure inclusive of levels of professionals such as Care Coordinators and licensed Social Workers; c. Reproductive health specialists’ (maternal fetal medicine, psychiatry, psychology) access to acknowledge how toxic, chronic stress and adverse mental health impact women, whether during pregnancy or interconception/non-reproductive; 204 ii) Health information technology system integration for population management and individualized care planning; iii) Neighborhood partnership and activation with Community Based Organizations as priority Social Care providers integral to a women’s health. To help achieve this new model’s aims, the department was a part of a national demonstration project from 2013 - 2017 called, “Strong Start,” from the Centers for Medicare and Medicaid Services (CMS), Innovations branch. Now the standard prenatal package in DHS, MAMA’S Neighborhood provides pregnant women comprehensive prenatal services that emphasize care coordination and care planning to integrate the physical, social, behavioral and mental health needs of clients. The intake assessment guides patient risk stratification and subsequent care coordination. Patients receive enhanced clinic-based services including: 1:1 contact with their assigned care coordinators and social workers and a full range of prenatal and postpartum care at scheduled intervals based on the risk assessment and individualized care plan. Vital to the MAMA’S Neighborhood demonstration was its Neighborhood of service agencies prepared to help pregnant women with their range of social, health and mental health needs. In discussion with these Neighborhood Network partners, we have identified many of the gaps in existing programs as well as which populations are most challenging to engage in care and/or have the most limited access. Through these community engagement exercises and on- 205 going conversations, the department has jointly developed the Whole Person Care –MAMA’S Visits model to specifically address the unmet need for services in the prenatal service community. This manual provides basic information to MCMH teams as they develop the model for DHS. 2. MAMA’S Neighborhood - Design The MCMH is a perinatal care practice that includes basic elements of a patient-centered medical home: a physician/clinician led team, a panel of assigned patients, the use of a patient registry, and care management. Additionally, the MCMH will include the complement of nutrition, health education and psychosocial services offered through the California Comprehensive Perinatal Services Program (CPSP). MAMA’S Neighborhood provides for enhanced services engaging and coordinating the support services of a formal Neighborhood of care which will surround the MCMH in order to provide care that addresses patient needs in the realms of substance use, food scarcity, housing instability, mental health and resiliency. This linked, collaborative model enhances the content of prenatal care by explicitly engaging community organizations in the plan of care, creating a true neighborhood for health with multiple pathways to care. Whole Person Care – MAMA’S Visits The MAMA’S program for Whole Person Care (WPC) will offer comprehensive care management services based in a Mobile Care Team (MCT) aimed at providing wrap-around services for those women who are pregnant and at high-risk for substance use, social stress including violence, homelessness and food scarcity as well as mental health conditions that are associated with adverse birth outcomes. It aims to provide care to help mitigate the impact of these 206 stressors for high-risk women, optimizing the likelihood of healthy births, and, will address maternal psychosocial health as a foundation to support healthy infant physical and social- emotional health through partner involvement and parent/family support and socializations. MAMA’S Visits will have staff grouped into MCTs that service each of the eight Los Angeles County Service Planning Areas, and include the on-site perinatal clinical care, psychosocial assessment, care coordination, birth planning and discharge/release and transition planning at Central Regional Detention Facility (CRDF) women’s jail. Inherent in the mobile design of Whole Person Care are built in linkages with other Whole Person Care specialized programs, as well. This way, there is no wrong door to reach MAMA’S. Each MCT will consist of non-licensed, maternal infant health trained Care Coordinators with lived experience, and two licensed staff, including a nurse (RN) and a therapist (MFT or LCSW). Each staff member will be responsible for discipline specific tasks, Collaborative Care, and liaising care with one or more DHS clinical sites. The MCT will have standing care conferences with both medical and mental health clinicians to guide care delivery and provide consultation. The WPC-MAMA’S Visits model creates a synergy between the data driven Collaborative Care of the existing MAMA’S Neighborhood model with the intensive care management of home visitation, thereby extending the reach of both programs to most clinically complex clients ineligible for other home visiting programs. Figure 1 below depicts the essential roles of MAMA’S Neighborhood staff. 207 Care Coordinator (paraclinical, lived experience, MCH trained) (anchor, trusted relationship 1st, psychsocial asst, ICP, Rx for Health, f/u, neighborhood networker, Collaborative Care) Mental Health Therapist (MFT, LCSW, PsyD, PhD) (therapy, crisis management, care coordination prioritization, community linkages, behavior change, foundational emotional support and improvement, Collaborative Care) Clinical Care Team (MD and physician champion, CNM, RN as Site Nurse Lead, MFM, LVN, in-clinic admin staff, reproductive psychiatry) (empathic care, trusted shared decision model, summary sheet review, manage complex morbidities, population risk management, Collaborative Care, continuity care) Health Education & Resiliency (MPH, CHES, lived experience, MCH trained) (group support and classes, family engagement, health promotion, neighborhood partnerships) Figure 1. MAMA’S Neighborhood Team 208 Figure 2: Multi-system Construct of MAMA’S Neighborhood: How We Work MAMA'S Neighborhood Values Mothers first, relationship based, Vision All women have access to holistic care that is: coordinated, comprehensive, continuous, compassionate & culturally- attentive Mission Supporting pregnant women through holistic care that improves maternal & birth outcomes, and supports healthy infant development DPH Aim: Partnership for Healthy Births - CPSP certification - Educational materials - AAIMM Health Equity DHS Aim: Mother-centered, Coordinated Holistic Care - Medical Care @ DHS Women's Health sites - Care Coordination - Mental Health - Home Visits -Education & resiliency -Racial Health Equity DMH Aim: Bridging Mental Health - Therapy and psychiatry - Care navigation COMMUNITY BASED PARTNERS Aim: Seamless, Linked Care - Substance abuse, housing, food, partner violence, other mental health, mother education and support groups 209 3. Rationale Framework The MAMA’S Neighborhood collaborative approach is based upon several core assumptions that will serve to ground its implementation: Core Assumptions 1. Poor birth outcomes are often the result of multiple factors, including medical, social, and environmental determinants; 2. Screening and identification of high-risk mothers is inconsistently implemented, and intensity of service provision is not currently aligned with identified risks; 3. Care is fragmented and lack of coordination leads to missed opportunities to mitigate the determinants of poor outcomes; and 4. A comprehensive, coordinated public health approach that includes its three core pillars (physical, mental, social) is required to address the issue responsibly. 5. Supporting mothers to be healthy, resilient, connected and prepared sets the foundation for a healthy newborn and consequent infant cognitive, social and emotional development. Several system-level and operational changes will be employed that mirror the principles of the Patient-Centered Medical Home. These operational changes will drive the transformation of care delivery for the model. Core MCMH Principles • Service delivery within a maternal medical home can be complemented by community-based home visitation that is equally as comprehensive and mother- and baby-centered; • Service provision by multidisciplinary care teams will offer improved care coordination and patient access; • Patient-centered care coordination anchors service delivery for high-risk women, with service intensity determined by risk score; • Health Information Technology (HIT) utilization is required for population management; and, • Continuous quality improvement processes underpin model implementation to track process and outcome measures and support rapid-cyclical improvement. 210 Above and beyond the operational changes for the MCMH clinics, there are several core areas of concentration that will be the focus of intervention efforts. These have been identified in the literature as possible contributing factors to the outcomes of preterm birth and low birth weight that this model hopes to prevent. A global risk score is determined from a comprehensive assessment comprised of nine validated scales in these core concentration areas. Care coordination contact is driven by this score and adjusted as needed. Individualized care planning that accounts for her readiness to address issues is crafted based on the tailored needs of the mother. Core Medical and Psychosocial Areas: Substance Use – smoking, alcohol and drug use, including opioids Social Insecurity – food and housing instability Mental Health Instability – depression, anxiety, self-efficacy, PTSD, severe and persistent mental illness (schizophrenia, bipolar, etc) Intimate Partner and Environmental Violence – domestic, community Social Support – connectedness, resiliency, support network, toxic psychosocial stress Biomedical Risk – previous preterm birth and/or low birthweight, short cervix, infections, chronic disease 211 Figure 3. MAMA’S Neighborhood: Driver Diagram and improve maternal and infant mortality 212 4. MAMA’S Neighborhood: A Conceptual Model This prevention-driven and relationship-based model is grounded in three tenets: 1) the mother is the primary decision-maker in her own care; 2) mother-centered services and support will set the foundation for a healthy child; and, 3) a mother’s family and neighborhood are potential assets for support and are primary influencers in her decision making. First, mother being at the center shifts the paradigm from health system-centric to a mother- centered one, which lifts up the responsibility of health care providers to meet mom where she begins in her readiness to address issues; requires empathic, trauma-informed practices; and, sets the stage for mom to be her own “driver” in her care and for activating her energy from within to help herself grow and succeed. Number “2” is explained further as the anchoring of a mother to a positive support system (whomever it may be) and encouraging her power from within to be the healthiest she can be, provide a solid foundation for her baby to securely attach, with the quality of that attachment being the emphasis. As well, putting baby next to mom displays the proximity needed for optimal social and emotional development for baby, and conversely, the opportunity for humble learning during motherhood. Number “3” honors that a mother’s family, peer support network and community neighborhood are closest to her, and impact her knowledge, attitudes and chosen behaviors. Her 213 neighborhood is made an active component of the care plan that cradles her with trusted supports during her in her pregnancy, birth and postpartum up to 18 months. Designing interventions that shift the paradigm from top-down, provider/system centric to a mother-centered model levels the patient-provider relationship, focuses on trust, and respects mothers’ autonomy. MAMA’S Neighborhood focuses on activating the mother, her family and immediate social support and her ‘neighborhood’ agencies in advancing improvements in her care and health outcomes. Figure 4 is found below and depicts the concentric spheres of a mother-centric model of care. 214 Figure 4. Model of Mother Centered Care 5. The Concept of a Maternal Medical Home The medical home will function as the central point for coordinating care around the patient’s needs and preferences. The medical home will also coordinate information between all team members, which include the patient, family members, other caregivers, specialists, and non- clinical services as needed and desired by the patient within the Neighborhood of care. The Mother Centered Policies MAMA'S Neighborhood Family Baby Mother Figure 4. Mother Centered Care Model. Los Angeles County Department of Health Services, Moraya Moini, MPH and Erin Saleeby, MD, MPH, 2017. Adapted from Mother Centered Care Conceptual Model, Mother Friendly Childbirth Initiative Consortium. PHP Consulting, Moraya A. Moini, MPH, November, 2012. 215 following depicts the care transformation that DHS seeks to achieve in maternity care in Table 1. Table 1. MCMH Care Commitments CARE AS IS MOTHER-CENTERED MATERNITY HOME CARE My patients are those who make appointments with me Our mothers register with DHS as their maternity home and are offered both on-site clinical and home/community-based visitation by DHS team. Standard OB protocols determine care We systematically assess our mothers with a standardized comprehensive clinical and social care assessment that identifies strengths and areas of improvement needed. Patients are responsible for coordinating their own care A multi-disciplinary team of clinical and social care professionals coordinate internal and external referrals that are tailored to mothers’ individual needs based on risk level. Patients are given slips of paper with referral information for community- based services We actively engage and connect a multi-disciplinary Neighborhood Network of Care comprised of health and social care providers, which link together pathways of care for the mother. We assume we deliver high quality care because we are well trained We utilize evidence-based measures and quality indicators to aid in continuous quality improvement activities that support better perinatal clinical and psychosocial outcomes. We review patient charts at the time of visits to look for gaps in care We utilize electronic patient tracking and empanel (provider assignment) mothers to support continuity of care and identification of strengths and gaps in care. It’s up to the patient to tell us what happened to them We offer and track a diverse menu of tests, consultations, specialty care and follow-up utilized during perinatal care to support seamless and informed care. Clinic operations center on meeting the doctor’s needs We offer a proactive clinical and social care team that honors the perinatal period as a critical window for intervention and improvement for mothers. 216 6. Staffing Model and Team Composition Within MAMA’S Neighborhood, the Women’s Health Programs and Innovation department manages a total of thirty-two (32) clinic-based staff and forty-four (44) community home visitation staff regionally placed throughout the county. It will leverage the clinical staff existent at outpatient and delivery hospital sites, as well as newly hired central administrative staff housed under Whole Person Care central administration. Clinic Based Direct Service Providers Clinic MAMA’S Neighborhood staffing includes the following team members at each DHS MAMA’S Neighborhood clinic site: • 1 - 2 Clinic MD, CNM or NP (physician/clinician champion) • 1 RN (clinical care and Site Nurse Lead champion) • Varying number of LVNs for medical clinical operations • 2-3 Clinic Care Coordinators (CC) • 1 Health Educator (Assistant) • 2 - 3 LCSWs (therapists) • 1 Nutritionist (visiting) • 1 MFM specialist (birthing hospital locations only) Community Based Staff Eight regional Mobile Care Teams (MCTs), one per Service Planning Area (SPA), will provide home visitation to high medically and psychosocially at-risk mothers. This community based MCT includes: • 1 Public Health Nurse (PHN) • 1 Psychiatric Social Worker (Therapist) • 2 CHW Community Care Coordinators (CCs) 217 Centrally Based Staff who will support all SPAs • 1 Maternal Fetal Medicine (MFM) – for high-risk medical consultations, complex population management, interconception care continuity. • 1 Psychologist Consultant – for supervision of therapists and psychosocial education development for all staff. • 1 Reproductive Psychiatry MD Consultant – for medication management, complex psychiatric conditions (severe and persistent mental illness) and care planning • 1 Nurse Manager - for supervision and development of frontline staff • 1 Project Director – for strategic partnerships, education and training, budgeting, CQI Partnerships and Pathways to Care Under Whole Person Care management are centrally managed Associate Directors for Regional Collaboration that are responsible for building community partnerships with organizations that at- risk mothers frequent and which will provide easily navigable pathways to care. • Associate Directors for Regional Collaboration • Regionally specific, multidisciplinary sets of Neighborhood community based organizations to be a mother’s Neighborhood Network of Care such as food assistance, housing placement, early literacy, social support and family strengthening, father/partner engagement, violence exposure and PTSD, substance use/abuse (alcohol, drug, smoking), breastfeeding, infant development, and the like. Table 2 provides a description of responsibilities for each MAMA’S Neighborhood. 218 Table 2. MCMH Care Transformation Staffing Model Staff Position Main Role and Responsibilities Site OB Provider Champion (MD/NP/CNM) Public Health Pillar: Physical Health Role: “provider champion” Responsibilities: • On site provider (medical director or lead physician) • Models care that is collaborative, mother-centered, empathic and trauma informed, and evidenced based • Provides medical resident education on Lifecourse theory, Barker hypothesis, and impact of allostatic load of toxic stress on outcomes • Enacts guidance that accounts for her stressors and protective factors • Co-leads biweekly Collaborative Care all-staff meetings with the Site Nurse Lead and Care Coordinator that focus on risk-stratified case review and improving operational efficiency and effectiveness via rapid cyclical improvement discussions • Upholds that every clinic staff member, from front desk to nursing to discharge, is valuable in ensuring a positive patient experience and healthy unit-based team • References the patient’s Individualized Care Plan’s (ICP) at risk health domains in his/her visit with the mother, and elevates the Care Coordinator as a worthy resource in both anchoring her care and providing her community linked referrals • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well Site Nurse Lead (SNL) (RN, BSN, LVN in some circumstances) Public Health Pillar: Physical Health Role: “site nurse lead” Responsibilities: • Collaborates with all team members around their focus areas and facilitates the development and implementation of a comprehensive, interdisciplinary treatment plan focused on the ambulatory setting • References the patient’s Individualized Care Plan’s (ICP) at risk health domains in his/her visit with the mother, and elevates the Care Coordinator as a worthy resource in both anchoring her care and providing her community linked referrals • Oversees the coordination of care and communicates with patient, primary care provider, health care team and specialty care providers • Functionally supervises the Care Coordinator 219 • Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family and patient education and identified healthcare needs • Focuses on each care episode in the context of the continuum of care and their unique needs • Focuses on a small percentage of high-risk/ high cost patients at a high level of service intensity with the provider champion and MFM and other required disease specialists. • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well Care Coordinator Public Health Pillar: Social Care Role: “mother’s anchor to care, support and wellness” Responsibilities: • Builds trust and rapport with mother • Understands the association between the success of care planning on quality of the relationship • Performs options counseling with topic specific sensitivity • Works closely with MAMA’S core unit-based team members • Performs psychosocial health assessments and generates Summary Sheet/Care Profile for all unit-based team members to refer to • Care manages according to risk stratification scoring, but use paraclinical judgement on mother’s needs should the risk score seem off • Develops individualized, comprehensive care plans tailored to patient’s readiness, needs, protective factors and abilities. • Develops a Rx for Health designating linked referrals and resources desired by mother’s/patient’s said goals • Proactively assists patients with navigating the medical, social service, behavioral health systems and Neighborhood partners to encourage a supportive and networked system of care • Provides approved patient education materials • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well 220 Licensed Clinical Social Worker (LCSW) Public Health Pillar: Mental Health Role: “therapist” Responsibilities: • Provides clinical individual therapy and group cognitive behavioral therapy • Provides expert guidance on patients who present with severe and persistent mental illnesses • Provides expert guidance on care management prioritization and coordination to the Care Coordinator • Works closely with MAMA’S core unit-based team members: site nurse lead, provider champion, health educator and Care Coordinator • Provides approved patient education materials • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit based team to do so, as well Health Educator (HE): Public Health Pillar: Health Literacy Role: “health educator” “neighborhood liaison” Responsibilities: • Coordinates all aspects of health education and promotion • Recruits mothers to and conducts prenatal education and resiliency building class series • Conducts narrowly casted education and promotion campaigns to raise awareness of a topic • Spearheads all on site collateral materials replenishment and management to ensure racial, ethnic and linguistic awareness • Assists in partnership building in the Neighborhood • Partakes in evaluation activities to measure impact of their work, and in Collaborative Care meetings locally at their assigned site(s) • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well 221 Reproductive Psychiatrist (MD) Public Health Pillar: Mental Health Role: “reproductive psychiatrist” “mental health redesign-er” Responsibilities: • Clinically manages all severe and persistent mental ill mothers • Liaises with obstetricians on prescription medicines and medication management • Redesigns mental health pathways to care within site and countywide • Provides expert consultation to all unit-based team members in accordance with licensure • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well Women’s Health Psychologist (PhD) Public Health Pillar: Mental Health Role: “mental health redesign-er” Responsibilities: • Assists in the redesigning of mental health care pathways for women’s health • Participates in Collaborative Care meetings and care planning • Liaises with unit-based team • Provides expert clinical consultation on modalities of therapy needed for therapists • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well 222 Maternal Fetal Medicine Specialist (MFM) (MD) Public Health Pillar: High-risk Medicine Role: “perinatal high-risk specialist” Responsibilities: • Provides expert clinical medical consultation for high-risk, complex multi-morbid medical mothers • Participates in clinical review team meetings regarding necessary care planning • Advocates for and provides expert consultation for interconception care planning • Drafts expected clinical practice guidelines for obstetricians at DHS clinical sites • Provides letters of support for mothers needing assistance in their DCFS cases, if appropriate • Documents care in paper chart/electronic health records • Co-leads and/or participates in regularly scheduled Collaborative Care meetings • Participates in multidisciplinary team meetings for process improvement activities • Upholds racial, cultural and linguistic attentiveness when care planning, and encourages others on the unit-based team to do so, as well 223 7. Risk Stratification and Comprehensive Assessment Historically, the risk stratification algorithm for mothers was developed by the Executive Steering Committee at the beginning of the Strong Start – MAMA’S Neighborhood initiative in 2013. Through a process of collaborative discussion and literature review, determination of psychosocial risk domains, validated scales and weighting of those domain specific scores to create a Global Risk Score (GRS) was completed. Currently used, and now the standard of care, the GRS provides a framework for care coordination, follow up frequency, huddle discussions with nursing and provider staff, and case reviews during Collaborative Care meetings. The GRS’ are: level 3, extremely high-risk (follow up weekly); level 2, moderately high-risk (follow up monthly); level 1, relatively stable (follow up trimesterly). Risk stratification of care are designed to be an initial guide for service intensity and time related. The GRS was designed to stratify mothers’ risk level by the number and type of issue presented/shared. For severe situations, the risk calculator was designed to be sensitive and specific enough to place mom in the appropriate strata. Case load distributions per Care Coordinator roughly equal 60% level 1, 30% level 2; and 10% level 3. Nine risk domains comprise the comprehensive assessment and include: 1) Alcohol and Substance use 2) Tobacco 3) Interpersonal Violence 4) Depression 5) Anxiety 6) Social Support 7) Housing insecurity 8) Food insecurity 9) Biomedical history and complications Current analysis is being performed to test that sensitivity and specificity, including consideration of when and how validates scales within the assessment are asked. Research has shown that these attributes matter and can limit results. 224 Comprehensive, serial assessments, serial individualized care plans (ICP) and prescriptions for health (Patient Rx for Health) will guide the MCMH team in the delivery of appropriate care for the mother over the course of the prenatal and postpartum periods up to eighteen months. The comprehensive assessment is administered at intake, and per managed care guidelines, must be completed within 90 days of intake. This same assessment, in short form, is then administered trimesterly in the prenatal period, once postpartum within 90 days of delivery, and then once every three months until program end. Each time this assessment is administered, the Care Coordinator must update the ICP immediately for collective care management. Any number of Patient Rxs for Health can also be created to support the mother’s needs. All assessments plus PHQ-9 are to be entered into the “MAMA’S App” and will be migrated to ORCHID. Any printed ICPs and Patient Rx for Health must be submitted to Health Information Management (HIM, Medical Records) for scanning into ORCHID. 225 Figure 5. New Clinical Care Workflow 1 st Visit 2 nd Visit Check in Care Coordinator Welcome Options Counseling/Mother Asst of Goal Comprehensive Psychosocial Assessment Individualized Readiness Based Care Plan Rx for Health Linked Referrals and Plan Informed nursing assessment/preg. test/lab work Obtain next medical care appointment Check in Care Coordinator Welcome 1st Follow Up Appointment with Care Coordinator Nursing follow up OB Generalist/Midwife medical appointment ICP Summary Sheet Reference Sign up for Prenatal Health Education and Resiliency Classes Optional Reconnect with Care Coordinator Obtain next medical care and Care Coordination appointment 226 This assessment is critical in determining a mother’s protective factors and strengths, psychosocial health issues, related internal or community-based services, and the intensity with which the team will follow-up with the client. Within the comprehensive assessment are a set of validated psychosocial scales embedded within the comprehensive assessment. Intensity of follow-up, however, is not based upon the severity of any one condition, but rather a combined score of all of the components of the comprehensive assessment. Therefore, a client who is homeless, substance using and depressed will require more intensive and frequent follow-up than a mother who presents with one issue, like depression. However, clinical latitude is allowed in this service model to encourage appropriate care treatment and support. These important care planning decisions are made by the multidisciplinary MAMA’S team and through Collaborative Care reviews. 227 Figure 6. Schedule of Care Planning and Coordination Labor and Delivery 5th Visit (Pre-Delivery check in with CC, birth plan, PP prep, centering) 4th Visit - 3rd Tri (meet with CC, reasst., revisit ICP, discuss PNER classes) 3rd Visit - 2nd Tri (meet with CC, reasst., revisit ICP, discuss PNER classes) 2nd Visit (meet with clinician, ICP summary sheet review, lab review, +/- f/u with CC Welcome (intake asst, risk/stress scoring, ICP, Rx for Health, labs, nursing intake) 18 Months Postpartu m (Exit, Transition) PP Visit 5 (every 3 mo min) (meet in person/call with CC, reasst., revisit ICP, discuss PPER classes, father eng.) PP Visit 5 (month 4-6) (meet in person/call with CC, reasst., revisit ICP, discuss PPER classes, father eng.) PP Visit 4 (month 3) (meet in person/call with CC, reasst., revisit ICP, discuss PPER classes, father eng.) PP Visit 4 (month 2) (meet in person/call with CC, reasst., revisit ICP, discuss PPER classes, father eng.) PP Visit 3 (within 1 month) (meet in person/call with CC, reasst., revisit ICP, discuss PPER classes, father eng.) PP Visit 2 (within 2 weeks - CALL) (meet with clinician, ICP summary sheet review) PP Visit 1 (bedside or CALL within 1 week after discharge) (asst, MH asst, basic mom and baby care referrals and resources, BF) 228 8. Individualized Care Plan Individualized Care Plans (ICP) are generated and updated in ORCHID after each serial assessment at minimum. To track and manage how each domain is addressed and tailor care to the mother, the ICP offers a summarized version of both the domain specific and Global Risk Score, readiness to address issues, areas chosen as first step goals and status of resource receipt. Paired with this is the Patient Rx for Health, which documents the community resources chosen by the mother in her neighborhood. The ICP fulfills compliance to CPSP guidelines, as well. On the backend, the ICP is linked to a resource directory that filters by neighborhood and risk domain. It is auto-populated with domain specific risk scores and basic patient information to start. Consequently, the Care Coordinator can offer referral resources to the mother in a tailored fashion, and in printed form on the Patient Rx for Health coordinated by accessing MAMA’S internal care directory, 211, Maternal Mental Health Now provider directory, and One Degree. Mentioned above, two important aspects of the ICP exist: 1) readiness to address domain specific issues, and, 2) need, choice and acquisition of resources that address problematic risk areas. The ICP incorporates an essential tenet of behavior change theory which purports the importance of acknowledging where a mother begins when she starts the journey of tackling problem areas. Readiness is also a fluid tenet aspect and usually parallels the level of trust a patient feels with her/his case manager, therapist and the like. As the relationship develops over time with the professional caregiver, the mother has the opportunity to self-examine, self-regulate, and find the strength to be vulnerable enough to face past issues and traumas that may be at the root of the behavior associated with the problematic risk domain. 229 Care planning and the strength based, engaging and non-judgmental relationship necessary to enact care planning have been and will remain to be at the crux of the healing, growing and activation of a mother. The concept of “compliance and adherence” can be better understood through review of the ICP and case review with the Care Coordinator. An example of the summary ICP and Patient Rx for Health are shown Appendix D, page 41. 9. Care Management The Maternity Centered Medical Home (MCMH) Care Management Program Purpose Care management is a patient-centered, team-implemented, outcomes-focused process. Care Management (CM) within the LA County DHS Maternity Centered Medical Home (MCMH) supports the maternity centered medical home through a program of coordinated activities centered around the patient’s goals and needs. Patients’ goals and needs are defined through synthesis of individual patient goals and their current health status is ascertained by chronic disease(s) status, health-related behaviors, health care utilization and access, and health educational needs. Motivational interviewing techniques are used when conducting clinical and psychosocial care intakes and follow ups. The coordinated activities of the program inform each interaction between the patient and their medical home. Care in this system initiates with assignment to the medical home. Assessment begins with the patient’s first interaction with a Care Coordinator who, through initial contacts and standardized evaluation, assign appropriate next step care and contact for the 230 patient. Repeated throughout the patient’s time within the DHS MCMH, mothers will be formally followed up with using the Global Risk Score, ICP and Rx for Health as guides. Process The CM program is delivered primarily from the MCMH by community health workers, experienced nurses, nutritionists/dieticians, health educators, social workers, and other licensed and non-licensed professionals with the patient’s primary provider’s leadership. The DHS MCMH Care Management Program has four primary domains: • Screening and Prevention • Risk Reducing & Disease Specific Care • Utilization Tracking • Care Coordination The Care Management in these four domains defines the health needs and services of individual patients and is supported by defined, standardized, continuous and ongoing care management functions that: • Are not restricted to or dependent on any single individual role or job function but rather depend on the coordination, communication and active participation of all team members at various defined points in the patient’s time in the DHS MCMH. 231 • Assess and assign risk using standardized assessment tools based on information gathered and integrated through registry, lab data, visit history, utilization patterns, disease status and interviews and in response to defined and specific system triggers. • Based on risk, activates a coordinated response by appropriate team members who are notified and mobilized through clear and defined communication of responsibilities, primarily through registry task assignments. • Based on assessment information, create a Individualized Care Plan that includes standardized interventions, minimum contact intervals, evaluations and clear outcome measures. The CM assessment may trigger an increase or decrease in the intensity and/or level of services provided by the MCMH team. Standardized interventions may take place face to face, telephonically, through written communication, in group visits, through individual coaching or education or through other methods. Within the Care management program of the DHS MCMH, the Care Coordinator or Manager performs an important although not exclusive role in the implementation and coordination of the patient’s goals and plan of care and in the tracking and implementation and education. Each member of the team contributes in a unique and meaningful way to meeting the responsibility of care management for the patient. Care Management services will include the following activities: • Provides risk reducing, disease-specific and preventive health education. 232 • Assists in the development, implementation and evaluation of a multidisciplinary and individualized patient centered plan of care that includes appropriate education, access, treatment and transition of care. • Coordinates services to ensure continuity of care across the continuum and to facilitate patient care within their designated medical home. • Provides follow-up for post-hospitalization, post- emergency room and post procedural care. • Participates in the maintenance of the medical home panel in the registry. Reviews and collects information on risk factors from the patient and the patient’s medical record to assess risk status and documents it in the registry and medical record. • Coordinates medically necessary specialty and community-based services including communication regarding patient progress back to the care team. Prevents duplication, fragmentation and use of unnecessary resources. • Facilitates interdisciplinary team conferences, consultations, counseling as necessary • Identifies and reports variances from care plan and participates in clinical review with leadership • Documents all patient encounters whether face to face, via telephone, group visit or other type of visit. As part of Care Management, Health Education and Support are provided to complement clinical appointments through both group and one on one mechanisms. An explanation of their development and implementation are below. 233 10. Prenatal Education and Resiliency Building Support History In March 2015, Department of Health Services Strong Start MAMA’S Neighborhood and Healthy African American Families (HAAF) launched two Prenatal Education and Resiliency classes (PNER) at Harbor UCLA Medical Center. PNER classes featured two distinct curricula: prenatal education for expectant moms and coaches and resiliency building, all lasting 2.15 hours in duration. PNER classes were co-taught by MAMA’s Neighborhood health educator and staff member from community partner, Healthy African American Families (HAAF) for a total of six sessions. The health educator covered a different prenatal topic each week, as did the HAAF staff member. An added feature of the PNER classes is the additional face time patients receive with a registered nurse. Up to 30 minutes per class is designated for the nurse to answer general questions, concerns and interpret lab work with patients. Patients participating in PNER classes can bring one coach or support person to each class (e.g. father of the baby, mother, sister, or friend). Added value is given to this support person’s presence as they not only learn prenatal content, but personally benefit from the coping skills provided through resiliency curriculum. PNER classes also emphasize patient advocacy as facilitators encourage and teach women skills to advocate for their health care rights within the clinic and well beyond the care provided to them at the Department of Health Services of Los Angeles County. Resiliency Curriculum: An Evidenced Based Approach The resiliency portion of the class originated from the Community Partners in Care (CPIC) and their collaborative partnerships with community and academic partners such as, Healthy 234 African American Families, UCLA and the Rand Corporation. Together, these groups devised an evidence-based curriculum to reduce depression and low moods, tested in several populations. This curriculum was adapted and incorporated by MAMA’S Neighborhood with the hopes that the cognitive behavioral therapy offered through the resiliency curriculum could support self- awareness of low moods in expectant mothers and teach them strategies to combat low moods resulting from negative thoughts, anxiety and fear about the birth process, resulting in a less stressful pregnancy with positive birth outcomes. To date, the resiliency curriculum offered in MAMA’S Neighborhood prenatal education is a dynamic facet of the woman centered approach to prenatal health care. Patient Informed Suggestions to Enhancing the Prenatal Education and Resiliency Building Program In August of 2017, more than two years into the continued teaching of PNER classes, MAMA’S Neighborhood has seen some pronounced changes to the prenatal education program. These changes have been largely shaped by the feedback provided by patients and coaches residing in the classes. Notable changes to the PNER curriculum are featured below in Table 3. Table 3: Patient Feedback for PNER Class Structure Feedback Change Made Change Still in Effect? Not enough time given to evening class participants to drive from work to class or to get dinner before class. Push back the start of class from 5pm to 6pm ✓ Too much information covered in the postpartum section, felt overwhelmed, wanted to know more about birth control options Separated post-partum content for mom and baby into two separate sessions (now at 7 sessions). Birth control and pregnancy spacing taught alongside birth aftercare and postpartum depression. ✓ 235 Desire to learn about alternative options to pain management in labor Added a class on comfort techniques, originally taught by a Doula (now at 8 classes) ✓ Not enough time to cover both curriculum content in 2 hours and 15 minutes Added an extra 15 minutes to class to give enough buffer to include breaks and account for prompt end time of classes (now at 2 hours and 30 minutes) ✓ Low class attendance when hosted in community academic setting (Charles Drew University) Moved class to outpatient clinic where patients already frequent to receive prenatal care ✓ Demand for Spanish classes Launched program’s first Spanish class in the fall of 2015 at Harbor UCLA Medical Center (LAC+USC followed in winter of 2015, Olive View followed in Spring 2017) ✓ RN extremely helpful in class Kept the RN in the structure of the PNER curriculum ✓ Current Structure of Classes The current structure, curriculum content and logistics of the class are the result of an iterative process driven mainly by each cohort of the PNER classes. Every cohort was given an opportunity to share feedback ultimately informing our program how to make classes more patient centered and effective spaces for learning. Current structure of PNER is reflected below in Table 4. Table 4: Current Structure of PNER Classes Week Prenatal Topic Resiliency Topic 1 Welcome, introductions, class structure What is resiliency? What affects your mood and resilience? 2 Nutrition Pleasant activities to improve your mood 3 Exercise - prenatal yoga Harmful thoughts and how to change them 4 Breastfeeding Using support from others 5 Labor and delivery No resiliency due to hospital tour 6 Comfort techniques Practicing good communication 7 Postpartum care for mom Goal setting for me and my baby 8 Postpartum care for baby Celebrating your resiliency/graduation 236 Expansion of Prenatal and Resiliency Education Classes Since the launch of classes in Spring of 2015, MAMA’S Neighborhood has currently expanded to a total of five sites, including Harbor UCLA (South Bay, SPA 8), LAC+USC (Metro, SPA 4) and Olive View Medical Center (San Gabriel Valley, SPA 2) (all DHS birthing hospitals), and MLK Outpatient Care Center, Hubert Humphrey Comprehensive Health Center (both in South LA, SPA 6), and High Desert Regional Health Center (Antelope Valley, SPA 1). MAMA’S Neighborhood currently holds 9 PNER classes across five sites in Los Angeles County, one third of those classes taught in Spanish. Classes are taught by health education assistants and health educators of MAMA’S Neighborhood. 237 11. Change Package Table 5 is a comprehensive list of change concepts that will guide the transformation of care. Component Change Concept Description Component 1: Community Based Home Visitation 1a. Aim to enroll mothers in the prenatal period 1b. Warmly introduce the home visitor team throughout prenatal period for highest risk mothers, and no later than in the third trimester 1c. Solidify continuity of care during delivery, whether by DHS bedside or by phone if not a DHS delivery 1d. Ensure visit by the (Mobile Care Team) RN nurse within the first 2-5 days of discharge 1e. Provide home based visits biweekly by a Care Coordinator and/or Social Worker (counselor) and follow program schedule of visits Component 2: Continuous Team- Based Relationships 2a. Clearly link patients to a provider and care team so both the patients and provider/care team recognize each other as partners in care. 2b. Assure that patients are able to see their provider or care team whenever possible. 2c. Define roles and distribute tasks among care team members to reflect the skills, abilities, and credentials of team members. 2d. Cross-train care team members to maximize flexibility and ensure that patients’ needs are met. Assure the delivery of effective, efficient, client centered, and safe clinical care. • Define roles, distribute tasks, and provide appropriate training to team members. • Ensure links to appropriate perinatal, neonatal, and specialty care providers for high-risk consultation, lactation support, and postpartum follow-up. • Ensure that educational and community resource materials are up- to-date, organized and available at each prenatal visit, as well as between visits. • Assure improvement in care by documenting and communicating with the practice team, referral agencies and the woman about her on going, evidence-based Plan of Care. 238 • Provide clinical case management/home visitation services or referrals to evidence-based programs or other follow-up mechanisms for women/families with complex needs. Provide culturally and linguistically appropriate care at all points of contact. Component 3: Mother-Centered Interactions 3a. Assess and respect patient and family values and expressed needs. 3b. Encourage patients to expand their role in decision- making, health behaviors, and self-management. 3c. Assure communication with their patients in a culturally appropriate manner in a language and at a level that the patient understands. 3d. Provide self-management support through collaborative goal setting and patient action planning. Support women and their families in the management of their health and health care before, during and after pregnancy • Emphasize the woman's central role in managing the health and well-being of the family unit. • Use effective self-management support strategies that include assessment of self-management knowledge, goal-setting, action planning, problem-solving and follow-up. • Organize internal and community resources to provide ongoing self- management support to women before during and after pregnancy. • Develop with the woman a written, collaborative and culturally appropriate Plan of Care that includes identified support person(s), resources and needs, interventions, self-management goals, and recommended follow-up. Component 4: Engaged Leadership 4a. Provide visible and sustained leadership in overall culture change and specific strategies to improve quality and sustain and spread change. 4b. Establish a CQI team that meets regularly and guides the effort. 4c. Build the practice’s values on creating a medical home for patients into the staffing process. Create a culture, organization and mechanisms that promote safe, high quality care. 239 • Develop agreements that facilitate efficient and timely care coordination* and communication within and across public and private health and social service agencies to ensure appropriate and safe perinatal, postpartum and women’s health care according to standard guidelines. • Engage senior leadership and use an effective improvement strategy with measurable goals to support improvement at all levels of the organization that result in comprehensive system change designed to improve perinatal, postpartum and early infancy care with a focus on safe and equitable care for all.. • Establish and encourage on going, transparent systematic handling of errors and barriers to quality care. • Integrate the National Standards for Culturally and Linguistically Appropriate Services (CLAS) throughout the healthcare system. *Care coordination is assessing the needs and resources of the woman and family, linking the woman to appropriate services, and monitoring the care they receive. Component 5: Continuous Quality Improvement (CQI) Strategy 5a. Choose and use formal models for CQI 5b. Establish and monitor metrics to evaluate improvement efforts and outcomes and provide feedback. 5c. Enable feedback to team and for external reporting on processes of care and population outcomes. 5d. Obtain feedback from patients/families about their healthcare experience and use information for quality improvement. 5e. Ensure that providers, staff and patients and families are involved in CQI activities. Component 6: Enhanced Access 6a. Understand patient supply and demand and balance patient load accordingly. 6b. Promote and expand access by ensuring that established patients have 24/7 continuous access to their care team via phone, email or in-person visits. 6c. Provide scheduling options that are patient- and family- centered and accessible to all patients. 6d. Help patients attain and understand health insurance coverage. 240 Partner with community to meet the needs of pregnant women, their families and children. • Form partnerships with community coalitions, organizations and agencies to support and develop interventions that fill gaps in needed services for pregnant women and their families. • Advocate for policies to improve women’s health and early infant health and development before, during and after pregnancy. Component 7: Care Coordination 7a. Assess patients for level of acuity and risk. 7b. Provide standard interventions for identified prevention, chronic illness, and level of risk to utilization of higher levels of care. 7c. Enhance patient self-management. 7d. Directly link patients with community resources, facilitate referrals and respond to social needs. 7e. Have referral protocols and agreements in place with an array of specialists to meet patients’ needs. 7f. Proactively track and support patients as they go to and from MCMH and community-based services 7g. Follow-up with patients within a few days of an L&D triage visit or hospital discharge. 7h. Test results and care plans are communicated to patients. Component 8: Organized, Evidence-Based Care 8a. Use Planned Care interactions according to a comprehensive set of patient needs. 8b. Assure access to care management resources to provide more intensive support to high-risk patients. 8c. Use point of care reminders based on clinical guidelines. 8d. Enable planned interactions with patients by making up-to- date information available to providers and care team at the time of the visit. Ensure clinical care that is consistent with scientific evidence and within the woman's informed preferences. • Provide planned care and follow-up based on identified needs and risks, and according to evidence-based guidelines for content and timing of care. • Embed evidence-based guidelines for assessment, screening, interventions and follow-up into daily clinical practice. • Share evidence-based guidelines and information with women and families to encourage their participation in care decisions. 241 Utilize provider education strategies proven to change practice behavior. Adapted from: “Change Concepts.” The Safety Net Medical Home Initiative. Qualis Health, The Commonwealth Fund, Improving Chronic Illness Care. www.qhmedialhome.org. Adapted by Health Management Associates for Los Angeles County Department of Health Services, 2010. 242 12. Care Model for Perinatal Health 16 The Care Model identifies the essential elements of a health care system that encourages high-quality care. The model includes evidence-based change concepts under each element seeking to foster productive interactions between informed clients, who take an active part in their care, with providers, who are prepared with resources and expertise. This model provides the framework for the system level improvements that in combination will yield results in improving birth outcomes in each of MAMA’S Neighborhood Networks of Care. 17 16 Adapted from NICHQ Care Model for Child Health 2004; Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4 17 From Improving Chronic Illnesses Care at www.improvingchroniccare.org "ICIC is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation". 243 Figure 7. The Care Model for Perinatal Health Resources and Policies Community-Partnered Care & Enhanced Access Continuous Team Based Relationships & Care Coordination Organized Evidence Based & Patient Centered Care Family and Self Management Support Engaged Leadership Health Care Organization Prepared, Proactive Practice Team Supportive, Integrated Community Improved Outcomes Coordinated and Culturally Appropriate Care that is Patient-Centered, Timely, and Effective. * Adapted from the Chronic Care Model developed by Dr. Ed Wagner et al and LA Best Babies Network Informed, Activated Patient and Caregivers Partnerships Effective Programs Coordination Education Communication Outreach Care planning Care reminders Feedback/monitor outcomes Individualized plans Share date CQI strategy Evidence-based guidelines Specialist expertise Provider education Guidelines for women Team roles and tasks Continuity/Follow-up Referral networks Case-management Cultural / linguistic competence Support Woman’s role Information Planning & Coordination Leadership, goals, benefits, incentives Empanelment/ Registry & CQI 244 13. Model for Improvement Key Points The Model for Improvement will be used as you implement change at your sites to integrate the MAMA Neighborhood protocols into your daily clinical practice. Your tests of change will demonstrate how to adapt the implementation of MAMAs Neighborhood to the different conditions across DHS ambulatory sites. Using the Model for Improvement we will evaluate intended and unintended consequences of the changes, to maximize seamless implementation across DHS over time. Figure 8. Model for Improvement (Institute for Healthcare Improvement) Model for Improvement 3 Key Questions for Improvement What changes can we make that will result in an improvement? IDEAS What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURES Test Ideas & Changes in Cycles for Learning & Improvement Plan Do Study Act 245 The Improvement Model, developed by the Associates in Process Improvement and tested and used in many Institute for Healthcare Improvement-sponsored Collaboratives, is based on rapid tests of change or PDSA (Plan-Do-Study-Act) cycles. The Model for Improvement is the foundation of the improvement approach used in MAMA’S Neighborhood. It is built on three fundamental questions: 1. AIMS: What are we trying to accomplish? Improvement requires setting aims. MAMA’S Neighborhood has established an aims statement that focuses on reducing preterm birth and its associated correlates. 2. MEASURES: How will we know that a change is an improvement? MAMA’S Neighborhood will monitor changes in work flow and outcomes to make sure that the changes that are being made actually leads to improvement. Clinics will use ongoing, systematic data collection and analysis to track these measures over time. 3. IDEAS: What changes can we make that will result in an improvement? All improvement requires changes, but not all changes result in improvement. Although many ideas and changes are identified in the MAMA’S Neighborhood “Change Package”, sites need specific ideas that can be tested and customized to your local environment. Testing and learning for the testing is necessary to conclude that a result is an improvement. 246 TESTING: The PDSA Cycle -- PDSA stands for Plan, Do, Study, Act -- is a trial-and-learning method to discover what is an effective and efficient way to change a process. PDSA cycles are short and quick. Typically, they need only hours, days or at most, a few weeks to complete. The "study" part of the cycle is the key to learning what change leads to improvement. "Study" compels the team to learn from the data collected, to look at effects on other part of the system and on patients and staff, and under different conditions, such as different practice teams or different sites. Most importantly, the "study" phase is an ideal time to think through the change package to generate new ideas and approaches to positive change. Teams will be asked repeatedly to report on their tests of change and what learning occurred as a result of these PDSA cycles. The PDSA cycle can be used for different situations: testing new ideas, implementing changes that show promise for improvement, and to spread changes throughout a system. Question 1: What are we trying to accomplish? AIM: A specific, measurable, time-sensitive written statement of the accomplishments expected from each team’s improvement effort. A strong, clear aim gives necessary direction to improvement efforts, and is characterized as: • Intentional, deliberate, planned • Unambiguous, specific, concrete • Measurable with a numeric goal, preferably one that motivates significant improvement • Aligned with other organizational goals or strategic initiatives • Agreed upon and supported by those involved in the improvement and leaders 247 Different forms are useful, but should include: • What is expected to happen • The system to be improved • The setting or specific (sub-) population of patients • Specific numeric goals • Timeframe • Some guidance for carrying out the work Question 2: How will we know that a change is an improvement? MEASURES: Measures are indicators of change. To answer this key question (“How will we know that a change is an improvement?”), several measures are usually required. These measures can also be used to monitor a system’s performance over time. In PDSA cycles, measurement is used immediately after an idea or change has been tested helps determine its effect. In improvement, key measures and measurement should: • Clarify and be directly linked to aims or goals • Seek usefulness over perfection. • Be integrated into daily work whenever possible. • Be graphically and visibly displayed. • For PDSA cycle measurement, be simple and feasible enough to accomplish in close time proximity to tests of change. 248 Question 3: What changes can we make that will result in an improvement? IDEAS: Ideas for change or change concepts to be tested in a P-D-S-A cycles can come from the change package provided from the faculty or can be derived from: • Evidence - results of research / science • Critical thinking or observation of the current system • Creative thinking • Theories, questions, hunches • Extrapolations from other situations When selecting ideas to test, consider the following: • Direct link to the aim • Likely impact of the change (avoid low-impact changes.) • Potential for learning • Feasibility • Logical sequencing • Series of tests that will build on one another • Scale of the test (3 patients NOT 30) • Shortness of the cycle (1 week NOT 1 month) 249 Tips to make the most of PDSA cycles and tests of change: ✓ Think a couple of cycles ahead ✓ Plan multiple cycles to test and adapt change ✓ Scale down size of test (# of patients, location)….A “cycle of 1” ✓ Do more cycles, at a smaller scale and faster pace instead of fewer, bigger, slower ✓ Test with volunteers first ✓ Don’t seek buy-in or consensus for the test – particularly early on ✓ Be innovative and flexible to make test feasible ✓ Collect useful (and only just enough) data during each test ✓ Test over a wide range of conditions ✓ Learn from failures as well as successes ✓ Communicate what you’ve learned ✓ Engage leadership support The aforementioned care transformation components in this implementation manual were excerpted from the larger MAMA’S Neighborhood Implementation Manual (Standards of Practice). Discipline specific care protocols, policies and procedures are DHS specific and under review and cannot be shared at this time. Limited appendices are shared in the following pages to provide a limited set of care planning tools, also a part of the larger manual. 250 12. Appendices Appendix A: PDSA Cycle Test Sheet MODEL FOR IMPROVEMENT PDSA Planning Worksheet Team Name:_________________________________ _____ Cycle start date:_________ Cycle end date:__________ Care Model Component □ Self Management Support □ Clinical Information Systems □ Decision Support □ Health Systems □ Delivery System Design □Community PLAN: (Describe the change you are testing and state the question you want to answer with this test.) What do you predict the result will be? Plan for change or test: who, what, when, where How will you measure the outcome of the test? Plan for collection of data: Who, What, When, Where? DO: (Carry out the change or test; collect data and feedback. Describe what happened include reporting of any unexpected events. Begin analysis.) STUDY: (Complete analysis of data; summarize what was learned; compare your results to your predictions. What did you learn? Any surprises?) ACT: (Are you ready to implement the change you tested? Modifications or refinements for the next cycle; what will you do next? Plan for next cycle) A P D S 251 Appendix B. MCMH Effective Team Meetings Remember Why We Are Here: Changing the “ME” to “WE” – Putting the Mother First Tactics for team or group meetings or dialogue that is meant to be generative can be used for many activities that aim for coordinated and collaborative input. In community based or partnered work, supporting and facilitating an egalitarian environment is key to gaining trust, showing that one values authentic engagement and input, and generating outputs that are owned together and sharing of success. Within the MCMH Model at the Women’s Health Programs and Innovation, these tactics would support the shift in shared responsibilities, perspectives and expertise in regional service provision for the mother. As such, these could be used in the general/clinic based Collaborative Care team meetings, regional and clinic daily/weekly huddles, and within the Leadership structure on project specific committees. 1. Improvement Team Composition Who needs to be at the table for medical home team meetings? • It’s important to have the core team members present for most meetings. • Need the right mix of knowledge, skills, experience in the content being discussed. • Need to have diversity in system, technical, operations, decision makers depending on the changes being planned. • To keep the group at a workable size, consider temporary members, e.g., project specific, decision makers at decision points. 252 2. Protocol Meet with your team and determine your protocol for meetings. Some key roles that should be rotated are: • Meeting Facilitator – this person has the agenda and is listened to. • Action Tracker – The person who records decisions, plans, etc. • Timer – this person keeps track of time and indicates when it is time to forward the action. 3. Some Key Agreements / Ground Rules • Be on time – the meeting starts on time and ends on time. • One person talks at a time. No side conversations. Use a talking stick or other symbol if people don’t honor this protocol. • In a discussion – if either no one is talking or you have a feeding frenzy – use an exercise such as brainstorming and multi-voting after which you might be ready for a course of action or a bit more research with a due date. • Agree to speak in a way that takes responsibility vs. blaming for things that don’t work. “It didn’t work for our patients when we ran late. I know I did _______. What else can we do to make sure we are on time.” • Ask people to speak from the point of view of what they will do personally to rectify the situation. 4. Preparation • Schedule the meeting in advance, preferably a standing weekly or bi-weekly meeting. Block off enough time so that it is valuable. • Have an understood method to post the agenda and have ways for your team to contribute to the agenda ahead of time. • If you have a practice update, have someone come to the meeting prepared to present a standard update. • If you have PDSA cycle/s in process, identify the lead on the cycle to present and discuss next steps. • Have an agenda with some time frames attached and have your timer keep things on track. 253 5. Tone – Energy Level • Start your meeting off with a positive energy level. Use a statement that communicates: “we’re going to get something done that will make a difference.” • As you move through your meeting, even if you are problem solving, keep the tempo. • Include time for individual acknowledgements in every meeting. • End your meeting by reviewing an action plan generated during the meeting. End with a positive statement: “Great meeting, thanks for your good work.” “You guys are the best; thanks for your commitment to improving our practice.” 6. Participation • If meeting attendees are participating, they will learn more, have more to contribute and the meeting will be more valuable. • Make sure to call on each person to contribute so that certain people don’t dominate the conversation. • If a new procedure or protocol involves a computer or other equipment, go there and have a hands-on presentation; new information will be understood better with participation. 7. Respectful / Safe Environment • Agree with your team to stop gossip about team members. All promise to leave what is discussed in the meeting within the practice. If a personal issue comes up – ask the team to honor confidentiality. • Schedule a time with a facilitator to do a team communication exercise. • If your team is not used to meeting, they will have a lot to say and may say it all at once and the leader may feel attacked. This is a normal occurrence with teams who have suppressed communication. When you get in the habit of meeting regularly and providing a generous listening to your team, this will dissipate. • If one person verbally attacks or accuses another in a meeting ask them, “It sounds like you are unhappy with the situation – what suggestions or request do you have?” Even if you agree with the attacker, if you let this happen, you will lose the respect and the safety of the group. Source: PHP Consulting, M. Moini. 2005. Adapted from “Energizing and Effective Meetings: Keys to Success.” The Coaching Center, Austin TX. Adapted for LA County Department of Health Services, Women’s Health Programs and Innovation, MAMA’S Neighborhood Implementation Manual. 254 Appendix C. Process for Beginning and Maintaining Relationship Based Care Forms: <HIPAA form> <Informed consent form> <Psychosocial assessment> <Individualized care plan> <Rx for health> <SMART goal setting> When speaking to the patient, consider the following: • Her cultural background • Her literacy level • Her possible negative or adverse personal history e.g. early trauma • How she or her family feels about the pregnancy • Her family support and structure Make sure to: • Begin discussion with how she is that day, her reasons for coming in today and needs • Smile and genuinely “show up” for each initial or follow up appointment • “do your homework” by reviewing mother’s information, care, profile and care plan (if completed prior). This shows genuine intent to provide personalized care. • Take the time needed to discuss the program, her questions and concerns 255 • Remember that once consented, there is 90 days to complete her comprehensive psychosocial assessment. Thus, do not rush, prep each section, stop to discuss issues or discomfort seen/noticed, • Use motivational interviewing techniques o Ask open ended questions o Recognize the patient’s strengths o Listen and reflect back o Summarize what the patient discussed • Focus on building lasting and trusted relationships • Pay attention to her body language • Close appointment with recapping the discussion and her needs, itemizing follow up points, restating first “mini” goal mutually decided upon, and ask if she has any other questions. • Always follow up in the time frame to which you committed. 256 Appendix D: Summary Individualized Care Plan (ICP) (not in order of asst) Score (via scale) Readiness (1-3) (1=not ready, 2=unsure, 3=ready) SMART goals (concerns, mini-goals, stated “w i n s ”) Rx for Health Referrals Provided (electronically generated via ICP on App) Behavioral Health Drug Use Tobacco Use Interpersonal violence Social Health Social support Housing instability Food insecurity Mental Health Generalized Anxiety Depression Biomedical health Medical/Obstetric High- risk Factors 257 Appendix E: Sample Algorithm for Social Care Rx for Health Planning FOOD SECURITY HIGH SECURITY (LOW RISK) Call from CC to problem solve 1. Refer to WIC 2. Provide WIC docs Enter in ORCHID and MAMAS App ICP F/U every trimester Mini/usual check-ups done at each CC contact LOW SECURITY (MED. RISK) Refer to appropriate agencies (WIC, food banks, churches, FM, comm gardens 1. Fax referral to WIC 2. Provide WIC docs Enter in ORCHID and MAMAS App ICP F/U in 2 week with patient and agency 1. If pt becomes enrolled, F/U by CHW every month 2. If pt does NOT get enrolled, F/U by CC every 2 weeks VERY LOW SECURITY (HIGH RISK) 1. Call & fax agencies (WIC, food banks, churches) 1. Fax referral to WIC 2. Provide WIC docs Enter in ORCHID and MAMAS App ICP F/U in 2 -3 days with patient and agency 1. If pt is connected to WIC & food bank, F/U every 1 week 2. If pt does NOT get WIC or is delayed, F/U every 2-3 days 258 Appendix F: Self-Management Support to Establish Readiness What is Self-Management? • Patient-Centered Approach • Patient responsible for day-to-day care of illness using developed skills: o Problem solving o Decision making o Resource utilization o Forming partnership with provider o Action planning o Self-tailoring Elements of Self-Management Support • Delivery system design (e.g., planned regular visits for patients with chronic illness, follow-up telephone contact for patients making a behavioral change) • Decision support (e.g., care guidelines available at the point of care, clinician training) • Information systems (e.g., patient registries, computerized reminder systems for patients and clinicians) • Organization of healthcare (e.g., leadership) • Community linkages and resources (e.g., referral to behavior change professionals, community programs, or care management programs) Source: Glasgow, RE, Strycker, LA, Toobert, DJ, Eakin, E. A social-ecologic approach to assessing support for disease self-management: The Chronic Illness Resources Survey. Journal of Behavioral Medicine. 2000; 23:559. Why Self-Management? • Care for complications of chronic illness is CO$TLY • Change in approach: response to outcomes research • DHS Mission: Patient-Centered Care Approach to Self-Management In the past: Provider-driven prescriptive behavior change goal setting The new way: Self-management support • Must be patient driven/centered • Role as guide • Helping patient change behaviors that decrease risk and promote health • Realizing that behavior change takes time 259 260 Five A’s and Self-Management 1. Assess a. Knowledge b. Belief c. Behaviors 2. Advise a. Sharing information i. Disease ii. Treatment iii. Health risks iv. Health behaviors b. Tips for Sharing: i. Share most relevant to the patient ii. Keep advise as simple as possible iii. First ask what the patient already knows and build on that iv. Give in small doses 3. Agree a. Collaborate to set goals based on the patients’ interest/enthusiasm and confidence 4. Assist a. Team plays a vital role to assist with identifying real or potential barriers b. Assist with problem solving 5. Arrange Follow-up a. A follow up plan is important b. It communicates the team’s support and interest in the patient c. Can be arranged according to level of risk 261 Assess the Importance and Confidence of the Selected Goal Making it Work • Conviction and commitment can be quantified: o "On a scale of 0 to 10, how much do you desire to (name the change)?" o "On a scale of 0 to 10, how confident are you that you can (name the change)?" • When conviction is high and confidence is low, focus on helping patients identify resources, strategies and skills that can enhance self-efficacy. o Review past experiences, especially successes o Teach problem-solving and coping skills o Elicit social support o Encourage small steps that are likely to lead to initial success • Identify the patients’ barriers to taking action. • Agree. Addressing Barriers 263 S.M.A.R.T. Goals • Creating S.M.A.R.T.goals o Specific – A specific goal has a much greater chance of being accomplished than a general goal. ▪ Who: Who is involved? ▪ What: What do I want to accomplish? ▪ Where: Identify a location. ▪ When: Establish a time frame. ▪ Which: Identify requirements and constraints. ▪ Why: Specific reasons, purpose or benefits of accomplishing the goal. o Measurable – Establish concrete criteria for measuring progress toward the attainment of each goal you set. ▪ How much? ▪ How many? ▪ How will I know when it is accomplished? o Attainable – Choose goals that are important to you. ▪ Look for opportunities to bring yourself closer to the achievement of your goals. ▪ Plan your steps, and establish a time frame that allows you to carry out those steps. o Realistic – To be realistic, a goal must represent an objective toward which you are both willing and able to work. ▪ A goal can be both high and realistic ▪ A goal should represent substantial progress ▪ Compare your goal to prior successes that have been similar in the past, or ask yourself what conditions would have to exist to accomplish this goal 264 o Timely – A goal should be grounded within a time frame. ▪ T can also stand for Tangible - Experience it with one of the senses ▪ When your goal is tangible, you have a better chance of making it specific and measurable and, thus, attainable. • Getting started o Think of a goal that you would like to work on. This is the overall goal. o Example: “Get more exercise” • What’s next? o How are you going to accomplish that? o This is narrowing down the specific action. For the “get more exercise” example, this could be walking. • More detail please o What: “By walking” o When: “In the morning at 9am” o Where: “Around my neighborhood” o How Often: “ For 30 minutes, 5 days a week” o Question: Does this pass the SMART goal test? 265 S.M.A.R.T. Goal Worksheet 266 ---end excerpted MCMH Manual---
Abstract (if available)
Abstract
Poor birth outcomes, as defined by preterm birth and low birthweight, continue to plague mothers who face more psychosocial adversities. Not only do public health systems financially suffer, but families suffer, too, as they try to mitigate a higher risk of infant mortality, as a result, and longer recovery periods once discharged home, which can be several months after birth. These unrelenting negative experiences can take a toll on a mother, also, putting her at higher risk for postpartum depression and deeper feelings of guilt. Babies born too early (prior to 37 weeks) can experience lifelong struggles with social, cognitive, and physical developmental delays, including learning disabilities and chronic health problems. When born too early, the cost of a premature baby can rise to twenty-five time higher than a baby born full term (March of Dimes, accessed 2020). Unfortunately, if you are African American and/or Black race as a mother, the chances for these adversities are much higher than the average rate for all race/ethnicities, and daily life attention to mitigate possible predicators and contributors is critical. ❧ The rate of preterm birth in Los Angeles County and California is 8.9% and 12% respectively, with the highest rate in African American and Blacks (11.7%) (LADPH, Perinatal Health Indicators & LAMBS Reports 2016). Highest all race/ethnicity representations are seen in Service Planning Areas 1 (8.7%), 4 (9.4%), 6 (8.8%) and 8 (9.2%) (LADPH, LAMBS 2016). As well, in Los Angeles County, low birthweight rates were 7.1% overall and 11.7% for African Americans and Black infants. Mortality for infants and mothers is also of concern and major interest to public health and community advocates, as these rates are largely associated with pre-pregnancy, prenatal and delivery conditions, many sometimes unmanaged in lower socioeconomic groups. Mothers and infants suffer mortalities more by race, specifically and again, in African American and Blacks. Continuing to rise, rates of maternal mortality reported a ten-year average between 2007-2016 for African American and Blacks living in Los Angeles County at 65.8 per 100,000, a rate more than five times that of Whites (12.4 per 100,000). Infant mortality rates for Los Angeles County numbered 4.0 deaths per 1000 live births (years 2007-2016), with African American and Black babies dying at more than two-times the overall rate at 10.4 per 1000 live births (LADPH, 2018). These rates exemplify the dire need for monetary investment to tailor, race-specific, creative interventions to African American and Black mothers, but, more so, the absolute need for the Los Angeles County health system to honestly reflect on what can be done systemically to meet mothers where they begin and improve accountability, performance, transparency and quality of the preventive and direct health services provided. Instead of expecting trust from mothers because of the ego inherent in medicine, health systems can self-reflect and change their organizational values to be trustworthy. ❧ In the last twenty years, research literature has named birth outcomes disparities and published these findings
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Moini, Moraya A.
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Supporting a high value maternity system of care: prioritizing resilience of and relationships with mothers to improve maternal and child health
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adverse birth outcomes,care coordinator,collaborative care,community health worker,high value maternity care,infant mortality,interconception,LACDHS,maternal mortality,maternity centered medical home,MCH,MCMH,model for improvement,mother-centered care,OAI-PMH Harvest,organizational readiness,organizational resilience,perinatal care,postpartum,PTB,readiness-based care management,relationship-based care
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adverse birth outcomes
care coordinator
collaborative care
community health worker
high value maternity care
infant mortality
interconception
LACDHS
maternal mortality
maternity centered medical home
MCH
MCMH
model for improvement
mother-centered care
organizational readiness
organizational resilience
perinatal care
postpartum
PTB
readiness-based care management
relationship-based care