Low Country Healthy Start

Eliminating Disparities in Perinatal Health

South Carolina 17th Annual Rural Health Conference October 14-16, 2013

Virginia Berry White, LMSW Director

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Background

     Low Country Healthy Start (LCHS) is supported by a US DHHS, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau grant.

LCHS is a program of the SC Office of Rural Health. This is a community based program of HRSA, Maternal and Child Health Bureau.

SCORH was awarded the grant in 1997 and has competed for it in competitive cycles several times. The main office is in Orangeburg with satellite office space shared with partners in Allendale, Bamberg, and Hampton counties. 2

Service Area

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LCHS Objectives:

Service area is Allendale, Bamberg, Hampton and Orangeburg In 2011 there were 1687 live births born to service area families, of which 69% were African American   Eliminating disparities in perinatal health. Reducing the African American infant mortality rate.

    Reducing the percent African American infants born with low birth weights and other birth problems. Promoting interconceptional periods of at least 2 years.

Preventing relapses of risky behaviors.

Building access to appropriate services.

   Helping families find and use medical homes.

Building community awareness and promoting increased understanding of health risks, poor health choices and how to change.

Working with the local Consortia.

 Women and infants are followed for two infant years and two post-partum years. 4

Navigation – a critical service

 The perinatal system in the service area is fragmented. For example,  Only Orangeburg has a birthing hospital and obstetric providers practicing full time in the county.  Allendale, Hampton and Bamberg have some prenatal services available in the county but not full time and not with extensive hours.  All counties have some pediatric services available.

 LCHS works to help connect women and their infants with a medical home that wants to serve them and wants to help clients maintain and improve health. 5

Navigation – a critical service

 Issues plaguing AA population/Social Determinants of Health,  Social Environment---discrimination, income and gender  Physical Environment/Housing Quality & Availability-- where one lives and crowding conditions  Health Services---Access to quality health care and having or nor having health insurance  Chronic Stress  Resource Limitations  Employment Security 6

Navigation – a critical service

 Issues plaguing AA population (con’t)  Infant Mortality  LBW Births  Preterm Births  Neonatal Mortality  Inadequacy of PNC  Health of Woman  Limited Social Support  Late Entry into PNC 7

Life Course Perspective Theory

 A conceptual framework that helps explain health and disease patterns – particularly health disparities – across populations and over time. Instead of focusing on differences in health patterns one disease or condition at a time, LCT points to broad social, economic and environmental factors as underlying causes of persistent inequalities in health for a wide range of diseases and conditions across population groups. LCT is population focused, and firmly rooted in social determinants and social equity models. LCT is also community placed, since social, economic and environmental patterns are closely linked to community and neighborhood settings.

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Closing the Black-White Gap in Birth Outcomes: A Life Course Approach

 Michael C. Lu, MPH  Milton Kottlechuch, PhD, MPH  Vijaya Hogan, DrPH  Loretta Jones, MA  Kynna Wright, PhD, MPH  Neal Halfon, MD, MPH  Research 2010 9

12-Point Plan to Close the Black-White Gap in Birth Outcomes

 Interconception Care to Women with Prior Adverse Pregnancy Outcomes  Increase Access to Preconception Care to African American Women  Improve the Quality of Prenatal Care  Expand Healthcare Access over the Life Course  Strengthen Father Involvement in African American Families  Enhance Care Coordination and Integration of Family Support Services 10

12-Point Plan to Close the Black-White Gap in Birth Outcomes

 Create Reproductive Social Capital in African American Communities  Invest in Community Building and Urban Renewal  Close the Education Gap  Reduce poverty among African American Families  Support Working Mothers and Fathers  Undo Racism 11

Services and Staffing

 LCHS staff provide perinatal assessments, home visits, outreach, case management, education, intervention, screening, counseling, referrals, follow-up  Staff includes Masters level Perinatal Social Workers, Perinatal Navigators, Managers and administrative team members  The total number of FTE staff has decreased as funding has remained constant.  When necessary, LCHS uses contractual social workers and navigators to help deliver education, outreach, case management and home visiting services. 12

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LCHS Focuses on Meeting the Needs of African American Families

 LCHS derives much of our strength through persistence, focus and long-term experience in the service area. For over fifteen years, we’ve worked with others to eliminate disparities in perinatal health.  We are known as authentic, informed, trusted and strongly connected to the African American community in these four rural, underserved counties.

 LCHS works in partnership … by design.  We have carefully developed, and we nurture, relationships with essential health providers to understand provider issues as well as client needs and often acts as a broker.  Work in rural communities is hampered by resource limitations and provider capacity but there are distinct advantages.

   We know our partners and they know us. We know about the community we serve.

We know about rural South Carolina.

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Private docs, nurse midwives, PAs Title V/Health Departments Community Health Centers DAODAS Mental Health Partnerships Program Participants DSS Schools Faith Leaders Workforce/ Career Development FSLC Families Businesses Hospitals 15

Maximizing Care Coordination Through Partnerships

To eliminate disparities in perinatal health, LCHS works in partnership with:  Clients and Family Members    Faith, Business, Education, Volunteer and Civic Leaders Perinatal Providers Other Health, Education and Social Service Providers LCHS has a local Consortia representatives of many of these key partners.  The Consortia meets at least twice a year.

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Successful Partnerships Perinatal Provider Advisory Group

Consortia.

– part of  Meets at least twice a year to review progress, identify barriers and accomplishments, identify where more investment is needed, advise LCHS.

 Made up of clinical staff from the birthing hospital, private obstetric practices, Federally Qualified Health Centers, county and district health departments, regional perinatal centers.

 Essential partners in eliminating perinatal disparities. 17

LCHS PPAG

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Successful Partnerships

Multi-disciplinary Team Meetings

    LCHS Social Workers and Client Navigators meet with six major obstetric provider practices to identify and solve problems and manage individual cases. Teams meet monthly to discuss and plan action regarding specific clients, practice issues, determine client needs and required follow-up. Meeting exchange builds LCHS expertise and understanding about clinical and health system issues.

Obstetric providers rely on LCHS staff for client follow-up, education based on risk and to provide them with home and family life insight.

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Successful Partnerships

 LCHS is a part of the SC Department of Health and Human Service Birth Outcomes Initiative (BOI)   This is a state level partnership designed to improve birth outcomes.

LCHS’s input on the BOI Care Coordination Work Group is focused on rural and is informed by the work of the LCHS staff in day to day home visits, outreach and case management.  LCHS is working with DHHS on Proviso 33.34, Section E(2). This is the part related to four rural counties and OB/GYN services. The four selected counties are Allendale, Bamberg, Barnwell and Hampton.

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Work that…Works

 LCHS major interventions are:  Home visiting  Case management – including individual client risk assessment and plan development – prenatal plan, infant plan and reproductive health plans  Close follow-up and support for clients enrolled in the program  Outreach to find clients in need of services 21

Women’s Health Issues/ Best Practice Strategies

  LCHS works directly with pregnant women to help them understand and improve their health during pregnancy and the two year interconceptional period following delivery.

Chronic diseases, especially diabetes, hypertension and obesity, impact LCHS clients in the perinatal and interconceptional period.

 These chronic diseases also impact their other family members.

 LCHS staff work with clients, family members and the community to reduce risk and change behaviors to lessen the impact of chronic disease and improve health.  LCHS works with women to assure they have a health care home after delivery and throughout the interconceptional period. 22

Specialized Perinatal Education/ Best Practices Strategies

 Breastfeeding is important and African American women have been less likely to breastfeed.

  LCHS invested in a Perinatal Navigator becoming a certified lactation consultant, which led to direct counseling and work with clients to support breastfeeding.

LCHS conducts breastfeeding classes for clients and community participants; providing support to private practices to encourage breastfeeding, as well as working with the hospital and WIC program to promote breastfeeding.

 LCHS also has a Perinatal Client Navigator certified as a childbirth educator. The childbirth educator provides individual and group education to LCHS clients and community participants. 23

Reproductive Health/ Preconception Health

 LCHS has a robust Health System Action Plan designed to help LCHS clients increase the time between pregnancies to at least two post-partum years. This helps women:   improve their personal health.

  improve the health of infants.

achieve personal goals.

  potentially improve family economic well being.

reduce stress .

LCHS works with clients, partners and providers to help women choose a method that fits her life style, her future pregnancy plans and her future.

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Reproductive Health – An Essential Strategy

   • Most women in our program say they were not planning to become pregnant when they did.

Helping women obtain birth control methods that work for them has been challenging and rewarding. It is a two pronged strategy – work with providers and with women LCHS works with clients to encourage them to ask for a method before leaving the hospital.

    During the prenatal period, LCHS staff provide clients with education about effective birth control methods, risks and benefits and develop a Reproductive Life Plan.

Work with clients to choose a method and explain how to receive the method of choice. Work with clients to request a Depo Provera injection before leaving the hospital, allowing time to arrange to receive the method she wants to use.

Follow-up, tracking and encouraging women to select and use an effective birth control method is one of our key success strategies. 25

Reproductive Health – An Essential Strategy

 Hospital and obstetric partners work diligently with LCHS to help clients leave the hospital, after delivery, with an effective method.  Providers helped design the strategy and are invested in assuring women have access to effective methods.

  Providers work closely with LCHS to help women receive the Long Acting Reversible Contraceptive methods they want to use.

Providers have invested in problem solving and creative solutions.

 Policy and financing have hampered efforts but providers, LCHS staff and women have continued to push for effective methods.

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Number of Clients Case Managed by Type

Source: LCHS Data Base, 2013 27

Postpartum Clients Leaving the Hospital with an Effective Birth Control Method

Note: Effective methods include Depo Provera injection, Implanon, IUD or tubal ligation .

Source: LCHS Data 28

Following is information on results and progress in the service area …

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Low Country Healthy Start (LCHS) Decline in Infant Mortality 2005 2011 % Decline

LCHS Service Area* African American IMR Infant Mortality Rate (IMR) South Carolina (SC) African American IMR LCHS Service Area Total (All Races) IMR Total (All Races) SC IMR

Total United States IMR

LCHS Service Area African American IMR SC African American IMR LCHS Service Area Total (All Races) IMR Total (All Races) SC IMR

12.6

14.7

11.1

9.5

6.87

2005-2007

16.8

14.0

14.3

8.8

7.7

12.6

7.7

7.4

6.05

2009-2011

11.2

11.9

8.9

7.3

39%

14% 31% 22%

12% % Decline

33% 15% 38% 17% * Service Area includes Allendale, Bamberg, Hampton and Orangeburg counties. IMR is per 1,000 live births. Source: SC & LCHS Service Area data from SC DHEC; US data from CDC, National Center for Health Statistics.. 30

The infant mortality rate for LCHS clients in 2010, 2011 and 2012 was 0 per 1,000 live births. In these three years there were 759 live births.

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Selected data and outcomes follow. The graphs are related to clients enrolled in the LCHS program. The data source is LCHS.

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First Trimester Entry Into Prenatal Care

88% 87% 86% 85% 84% 83% 82% 83% 81% 2010 Source: LCHS Data Base, 2013 2011 86% 2012 87% 1st Trimester Entry Into Prenatal Care 33

% Clients Receiving Adequate Prenatal Care

Source: LCHS Data Base, 2013 34

Percent Low and Very Low Birthweight Infants

Source: LCHS Data Base, 2013 Note: Includes all live births . 35

While we have made progress –– more is needed to sustain, increase, expand and enhance progress.

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Focus on the Community

  We have developed strong community partnerships and support.

Our annual infant mortality awareness luncheon is our signature event designed to educate and motivate citizens, recognize clients as leaders and promote scholarship and clients continuing their education.

    We had over 500 engaged people participate at the September 2013 luncheon.

We conduct annual community vigils focusing on remembering infants who died and their families.

We recognize providers and individuals who make a difference day in and day out.

We help some families, by community champions contributing funds, with essentials of life. However, there are simply never enough resources to meet the needs of our clients as many live in poverty.

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LCHS Consortium Retreat

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Focus on Education and Scholarships

 We work with clients and encourage them to get back in school, to finish school or to go on to higher education.

 Fund raising helps us provide scholarships for students who don’t have resources to continue their education.

 We have real working partnerships with our colleges and technical schools, specifically with South Carolina State University, Voorhees College, Orangeburg Calhoun Technical College and Denmark Technical College.

 Our work with clients on their reproductive life plan is tied to education planning and helping make the connection that more education leads to increased work opportunities, choices and income. 39

Partnership with Orangeburg Calhoun Technical College

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LCHS 2013 Scholarship Recipients

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Focus on Jobs

       We work to develop job placement opportunities for clients and partners.

 Consortia members help with this.

The technical schools help our clients and their partners with improving work readiness skills, developing a resume, and finding jobs.

We work with the Job Corps in Bamberg. We have success with EZ Shop interviewing and hiring our clients. The Healthy Tomorrows Program helps selected clients develop skills and confidence to acquire good positions.

Some of our clients are enrolled in CNA programs as a result of partnerships developed. Job placement is essential as parents want to be financially stable and build a good life for their child(ren) and themselves.

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Focus on Males

   Grants have been written and opportunities and resources actively sought to reach young men.

  LCHS recognizes that young men about to become fathers (or who are fathers) need support, education and help to be stronger, reliant, engaged fathers, partners and providers.

LCHS developed, in collaboration with community partners, a series of modules designed to build on the assets available in the Low Country – especially young men and successful men willing to teach, mentor and assist. We are calling our male outreach and assistance – Opportunity

Knocks.

We are using the 24/7 curriculum.

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Empowering Men to Become Outstanding Citizens and Parents

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Opportunity Knocks Fatherhood Program

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Continuing Concerns …

 No other group in the service area is focused on perinatal health and helping African American infants be born healthy. For continued progress – there must be continued funding and sharp focus.  Supporting rural, perinatal providers to continue providing health services in impoverished communities is essential.  Helping women understand and reduce chronic disease and the impact on themselves and their family is essential.  The lack of accessible, available mental and behavioral health services is a major concern.  Affordable, available, accessible, quality child care that allows women to go back to school or work is desperately needed.

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Continuing Concerns …

 From the first year of work through today – transportation remains a major barrier for almost every aspect of the work.

 There are many gaps in social and educational services in these rural counties and the gaps are growing wider.  Poverty is crushing and rampant.

 Jobs that pay a living wage are scarce.

 Employment and education opportunities must be expanded and direct investments made in helping young African Americans connect to and take advantage of those opportunities.  Maintaining interest in health policy issues for rural communities is challenging. 47

Welcome Challenges

   Developing a circle of meaningful support for young people to improve their chance for a healthy future is an exciting challenge.

Understanding, explaining and making the life course perspective a valued part of reducing disparities in perinatal health, and improving overall health, is essential. Continuing to find, develop, build and harness resources to eliminate disparities in perinatal and overall health requires a community approach and community, state and federal leadership and resources. 48

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