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					 Integrating Psychosocial
Screening and Referral into
       Prenatal Care

               by
   Ellen Hutchins, Sc.D., M.S.W.
         BACKGROUND


Changes in the health care delivery system
Psychosocial issues are multifactorial
Pregnancy as a window of opportunity
             OVERVIEW

 Issues to address:
   Information on the impact of psychosocial
    services on pregnancy outcome
   Barriers to screening and referral,
    particularly with private sector providers
   Strategies for integrating psychosocial
    screening and referral into prenatal care
   The role of partnerships
        SETTING THE STAGE

Growth in managed care
Private providers seeing more diverse
 clientele
Women’s changing roles
       WHAT ARE PSYCHOSOCIAL
            PROBLEMS?

Definition of psychosocial
Greater understanding of
 range of “stress” (Thompson 1990)
Role of psychosocial
 services
 IMPACT OF PSYCHOSOCIAL SERVICES
     ON PREGNANCY OUTCOMES

 Difficulty in determining impact
 Clinical vs. other factors
 Studies have looked at various factors:
   Stress
   Depression
   Domestic violence
   Substance Use
              STRESS


Preterm labor link (Teixeira et al 1999)
Poor birth outcome link (Nuckolls et al
  1972)

Low birthweight (Sable, Wilkinson 2000)
Conclusions
            DEPRESSION

Prolonged stress can lead to depression
9-11% of women are depressed during
 pregnancy (Holcomb 1996)
Depression linked to health problems in
 pregnancy.
      DOMESTIC VIOLENCE


4-8% of pregnant women experience
 domestic violence
ACOG recommends routine screening for
 intimate partner violence
        SUBSTANCE USE


Association with poor pregnancy
 outcomes
Prevalence in pregnancy
Linked to other psychosocial factors
ACOG screening recommendation
          ARE PSYCHOSOCIAL
         SERVICES EFFECTIVE?

 Physicians want proof
 Direct evidence is hard to obtain:
   Difficult to identify causation
   Difficult to control for multiple
    factors/interventions
   Few programs have been
    evaluated
         ARE PSYCHOSOCIAL
        SERVICES EFFECTIVE?

Studies suggest that psychosocial
 screening and intervention can make a
 difference.
Data suggest that early identification and
 referral for women at risk is worthwhile.
    WHY SCREEN AND REFER


 Screening allows for identifying risk
 Referral allows for comprehensive
  assessment, intervention and treatment.
          INTERVENTIONS:
       SCREENING & REFERRAL
 Many prenatal care providers fail to
  screen routinely for psychosocial issues:
   Lack of screening and assessment protocols
   Lack of prompt in medical chart
   Lack of screening tools
   Unclear when a problem poses health risk
   Unclear how to treat identified problems
   Don’t know who should screen
       INTERVENTIONS:
     SCREENING & REFERRAL

 Barriers to referrals:
   Lack of familiarity with community resources
   Doubt that treatment works
     DEVELOPING SYSTEMS

How to integrate screening and referral
 into prenatal care
Highlighting one innovative strategy:
 partnerships
    EXAMPLES OF INNOVATIVE
         PROGRAMS

General approaches
Public/private partnerships
   PARTNERSHIP EXAMPLES

 Alcohol Screening Assessment in Pregnancy
  (ASAP): (Massachusetts)
 Comprehensive Perinatal Care Program/Health
  Net (California)
 Alcohol Screening Initiative (Illinois)
 Screening, Assessment, Referral, Treatment
  (SART) (Fresno, California)
 Mobile, Alabama
 New Orleans, Louisiana
                   ASAP

 Screening and referral for alcohol and
  other substance use
 Pulled in providers
   Gave them data to prove it was worthwhile
   Gave them tools to make screening easier
   Provided information to facilitate referrals
 Has projects in 13 sites
            CPSP/HEALTH NET

 CPSP is mandatory under Medi-Cal
  managed care
 Health Net health plan certifies providers,
  provides screening tools and
  reimbursement incentives
 Evaluations indicate good rates of early
  screening and reduction in numbers of low
  birthweight babies
           Illinois’ Alcohol
         Screening Initiative
 Targeting 7 Prenatal Clinics
   Had a 10% Screening Rate
   Community helped design intervention
   Provider screening --- less than a minute
   Illinois pays for nursing assessment -
    Medicaid reimbursable
   Drug treatment linkage on-site
   Now have about a 90% screening rate
Screening, Assessment, Referral, and
Treatment (SART) - Fresno, California

 Developed community team consisting of
  OB/GYN, pediatrician, contract-writers
 Showed cost savings due to providing
  drug treatment
 County used funds to build a drug
  treatment program
 CPSP workers do assessments in MD’s
  office
        Mobile, Alabama

 Mistrust in community due to fear of
  punitive sanctions against pregnant,
  addicted women
 Developed team by drug court judge
 Diverted drug court resources into drug
  treatment for pregnant, addicted women
   New Orleans and Fresno

 Developed team via strategic planning
 Created central database to identify
  available drug treatment slots
 Drug treatment programs enter data daily
 Provides up-to-date directory of drug
  treatment slots
       PARTNERSHIP BUILDING:
          COMMON THEMES
 Started small and        Minimize providers’
  build up                  workload
 Overcome denial with     Assist with human
  data                      resources issues
 Provide tools and        Secure funding to
  training to make it       support the program
  simpler for providers
  to participate
              CONCLUSIONS

 Psychosocial interventions in pregnancy
  can improve health outcomes
 Psychosocial screening and referral need to
  be routine part of prenatal care
 Public/private partnerships have been
  developed to create psychosocial screening
   referral systems…but we need more of them

				
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