Every baby deserves a healthy mother for the long term.

The Women’s Health Council of RI recommends recasting women’s health from a focus on conception to long-term comprehensive care regardless of child-bearing status.

Good to Know

The leading cause of death for women is heart disease, yet most provider and payor focus remains on breast and gynecological health.

Symptoms experienced during pregnancy serve as a window into long-term health risks like heart disease, COPD, obesity  and diabetes.

Early awareness for both provider and patient can help change behaviors and start preventive care early across a wide range of women’s health issues.

Roadmap to Care

Link obstetric care to on-going primary care.

Encourage providers to train across disciplines and systems. Include obstetrics in the medical homes model.

Improve communication between the various health care disciplines.

In Your Practice

Recognize the early signs of risk from pregnancy health results such as pre-eclampsia and gestational diabetes, and environmental issues like smoking, poverty and domestic violence. Include these notes in patient’s files when transferring from OB-GYN to PCP.

Recommend a PCP visit one year following pregnancy.

 Women’s Health

Good to Know

Obesity continues in large part because all the systems – healthcare, education, food distribution and physical locations – conspire to make the healthy choice the most effortful.
Violence against women continues because it is ages old, on-going, systematic and often culturally sanctioned.
When obstetric results are not linked across disciplines through primary care, women’s future risks for diabetes, obesity, depression, hypertension and heart disease are ignored and care opportunities missed.

And when the aggressive marketing tactics of tobacco companies are combined with the addictive nature of nicotine, simply suggesting a patient quit their lethal habit is seldom enough.

Roadmap to Care

Research shows that focusing on numbers and spending millions of dollars on health education has not created change. Rather than publishing papers and articles, focusing on behavioral tactics bring results because they:

• create a new environment
• encourage better choices
• inspire new behaviors
• provide empathy and collaborative engagement

Today, New Policies developed by Council members and presenters are improving the availability of health care, improving the presence of healthy food, limiting the reach of tobacco, and de-stigmatizing domestic violence so it is no longer hidden.

In Your Practice

In the Clinical Care setting, New Tools provide screening language, data and procedures that help providers create an environment in which their patients may make better choices.

On-going Education via Events for providers includes data and statistics, but also teaches the language that establishes trust with patients while screening, creates and takes advantage of teachable moments and helps patients choose behavioral change.

Information on this website showcases the Council’s areas of focus to date:  Women’s Health in terms of obesity and exercise, Intimate Partner Violence, Smoking Cessation, Pregnancy as a health stress test, and a new focus on Bridging Physical and Behavioral Health in the area where women are at high risk: depression and suicide.

“In all these areas,” Dr. Rosene said “We need to continually address new program, policy and payment models.”

Lt. Gov. Elizabeth Roberts, MBA, greeted attendees by saying “Women’s health is a big determinant of family health.” She noted that people at this conference are changing the healthcare landscape. And policy makers are increasingly aware that they now have the opportunity to redefine health reform to get the healthier outcomes we all want.

Linda Carpenter, MD spoke in detail about the interface between depression and physical illness. 1 in 10 Americans have or had or will have Major Depressive Disorder. Patients typically focus on physical health with their primary care provider and don’t mention emotional or mental health. In 69% of patients, only physical symptoms were reported but all went on to meet criteria for depression. In describing how to recognize depression, the physician starts with 2 simple questions to determine if there has been a change in sense of well-being and a change in functioning. Dr. Carpenter’s slides showed the longer list of symptoms, including loss of hedonic drive and hopelessness leading to suicide. While there are multiple factors contributing to depression, early childhood stress including mother’s stress while infant is in utero, puts the patient at greater risk and makes recovery more difficult.

Teri Pearlstein, MD reviewed current treatment protocols for depression and suicide prevention. She stressed that primary care providers who screen for depression need to know where to refer patients for further evaluation and treatment. Screening is most beneficial when staff-assisted care and follow-up systems are in place. Evidence-based treatments for depression include psychotherapy, medication and alternative treatments, Efforts are ongoing to establish integrated care, ideally coordinated by care managers at regular PCP visits. The easy accessibility and follow-up of care is necessary because depressed patients face many barriers to receiving treatment. There is a 50% chance of another episode after first remission and anti-depressants work only 50-60% the first time.

Dr. Pearlstein also described the progressive phases of suicide, which begin with the idea, then thoughts, followed by plans. Successive suicide plans and attempts grow in intention and lethality until patient is successful or there is an intervention. She noted that suicidality may be a risk with anyone first starting anti-depressants and should be monitored.

Beatriz Perez, MPH, discussed suicide as a public health issue. In her role with the RI Department of Health, she described statewide violence and injury prevention programs she administers for the CDC and SAMSHA. She noted that RI women are below the national average for suicides, but suicide in men is showing a steeper increase than the national rate. Ms. Perez rarely sees an individual with just one risk factor and cautioned that any screening should consider multiple factors. Her programs make an effort to get to children at risk before depression sets in. And she teaches parents in at risk neighborhoods how to suicide-proof their homes by removing weapons and making medications unavailable.

Michaei Fine, MD, Director of the RI Department of Health,introduced the keynote speaker Regina Benjamin.

US Surgeon General Regina M. Benjamin, MD, MBA began her talk by observing that community events such as our council are important: they allow one person to stand up and make a difference whether in practice or policy.

Dr. Benjamin’s purpose as America’s Doctor is to stop illness and disease before it starts by using an integrative and holistic approach. She learned early in her career that practicing medicine was not about medicine alone, so she became involved in every organization that might help her patients receive better health services.

Today as Surgeon General her focus is on prevention and eradicating preventable causes of illness and disease.

In addition to the new American Affordable Healthcare Act, her policy agenda includes

• Let’s Move – supporting First Lady Michelle Obama’s exercise programs, especially for children and people over 50
• Addressing poverty, which has greatest negative impact on health
• Promoting Surgeon General’s Call to Action for Breastfeeding
• Improving ratio of full-term births
• Improving access to health care
• Reducing smoking rates
• Slowing sudden growth of HIV and AIDS in young women
• Stopping intimate partner violence, especially with young people
• Stopping prescription drug abuse by young people
• Improving patient compliance with prescribed medications
• Supporting the UN program to reduce Non-Communicable Diseases
• Supporting the Girls Not Brides program to keep girls around the world from being sold as brides.

Dr. Benjamin’s solutions focus on providing the best information available to live a healthy life. She has created the National Prevention, Health Promotion and Public Health Council, and released a National Prevention Strategy(www.healthcare.gov/prevention/nphpphc/strategy/report.pdf).

Her approach combines state of art medicine with an integrative and holistic approach for:

1. Healthy and safe communities and environments (homes)
2. Clinical and community-wide preventive services for better outcomes
3. Empowering people with tools and information making healthy choices easy and affordable.
4. Elimination of health disparities

This approach she believes can reduce the five leading causes of illness and death.

“We need your help,” Dr. Benjamin said as she introduced a new campaign to help change how everyone looks at health. In her program, health is translated as joyful, active living and includes activities that bring joy.

Kicking off on December 2, 2011 is a radio campaign called the “Surgeon General’s Dance Break,” a 60-second music broadcast urging people to stop what they’re doing, stand up and dance for 60 seconds every day.

Her closing words of advice: “Take care of yourself first. Relax, enjoy, and dance!”

PANEL DISCUSSION

Moderated by Rebekah Gardner MD and facilitated by Lisa Shea, PhD

This wide-ranging discussion touched on the following topics:

• Build behavioral health treatment into primary care training.
• RI is moving to achieve universal health coverage by 2014.
• Integrated programs are going to work the best for keeping people out of hospitals and living more joyful lives
• Support advocacy groups to reduce mental health stigmas
• Intervene and help families at risk early on
• Patient-centered home initiatives
• Build depression screening into regular practice. This is a culture change for providers. Create engaging ways for patients to fill out screening instrument.
• PCP’s must follow up with patients because there is much more to treating depression than giving medication.
• AMA is looking at ways to reduce burden of paperwork and record keeping for PCP’s.
• Incorporate dentists; note correlation between dental problems and heart disease.
• Both telemedicine and social media represent enormous opportunities to improve care: younger generations plug in to health issues online.
• Include nurses, especially because they are skilled at getting out into the community.

CLOSURE Mary Reich Cooper, MD, JD

Dr. Cooper described RI as a “magical state,” because of people’s willingness to collaborate across disciplines on new solutions to improve women’s healthcare. “But,” as she thanked the participants, “we still have a lot of work to do!”

FOLLOW-UP The next Critical Workshop Training, Practical Applications: Bridging Physical and Behavioral Health, is scheduled for March 6, 2012. Presenters will offer more in-depth training for providers in how to implement the “chain of care” so patients receive more integrated and holistic treatment.

As Lt. Gov. Elizabeth Roberts said at the start of our 2011 Conference, “Healthcare today is like a deck of cards tossed up in the air. We have the opportunity to put the deck together in a new way, especially by building a better bridge between physical and mental health.”

While it may be difficult to get a handle on the overlap between physical health problems and emotional/mental health disabilities, what is known is that depression  (the most prevalent mental health disorder) is a medical problem that portends much worse outcomes for other health problems. Depression isn’t just in the head; it affects nearly every internal organ system adversely. Women are twice as likely as men to suffer from depression.

Suicide is the 10^th leading cause of death in the US and is recognized as a public health issue in RI even though the rate of suicide for women is below the national average. However, suicide rates for men are on the rise. The white population is most affected, although this population is least likely to live in poverty.

Good to Know

Depression has multiple causes. Some causes we have control over; others we do not. Preventable causes include: smoking, sedentary lifestyle, obesity, system inflammation and failure to report. But abundantly and strongly associated with depression is early childhood stress (abuse, neglect and poverty). Large-scale studies link this early life stress to many other preventable diseases.

Many risk factors for suicide are treatable but 80% of completed suicides went untreated. The number one cause of suicide is relationship separation or conflict. A program sponsored by the RI Youth Suicide Prevention Project focuses on core RI cities where more than 15% of children are living in poverty. Parents are taught how to suicide-proof their homes by such things as removing weapons and medication availability.

Recent studies show that some people are born with genes that protect them from depression and suicide no matter what their present or early-childhood stressors. Others have genes that indicate they are at greater risk.

Adverse social environments may impact physical and behavioral disease through epigenetic effects on genes that regulate physiological systems involved in stress and inflammation.

What blocks the bridge? Lack of access to universal healthcare. Access to good education. Decent housing. Stigma attached to mental health problems and suicide. Sensationalizing suicide by media.

Roadmap to Care

Both the fact and the perception of “maternal warmth” is a mitigating factor in all aspects of physical and behavioral health. We have the ability to improve preventive care by providing people with better resources to take care of themselves, their children and each other.

Because early childhood stress is implicated in both physical and behavioral health, Freud’s question, “Tell me about your childhood” turns out to be a relevant question with any disease.

Regardless of economic status, housing or education, we can improve resilience by intervening at an early age.  We may not be able to reduce poverty but we can lessen its effects on both physical and emotional health.

In Your Practice

A physical health provider writing an anti-depressant prescription and seeing the patient six months or a year later is not enough. Institute a “chain of care” for depression and other behavioral health risks. Primary care providers who screen for depression need to know where to refer patients for further evaluation and treatment. Screening is most beneficial when staff-assisted care and follow-up systems are in place. Screening tools from this website and other sources provide the first link on the chain.

Recommended:

• Initial screening
• Diagnostic interview
• Psychotherapy and/or medication and/or other integrated strategies
• Regular follow-up visits
• Treat as far as possible, including in-home psychotherapy

As Dr. Michael Fine, Director of the RI Department of Health, said at the start of our March 6, 2012 workshop: “We need to eliminate deaths from prescription drug overdoses.” RI has the third highest opioid pain-killer use in the country. And prescription drug overdose is now the leading cause of unintentional death in the state.

“Many, many people are involved with many, many prescription drugs, all prescribed by RI physicians and pharmacists.” These drugs are killing people. Dr. Fine’s goal is to work with the healthcare community to minimize misuse and still provide access to effective chronic pain management.

Good to Know

In describing the patterns of substance abuse in women, Panelist Catherine Friedman, MD, described it as an “exploding epidemic.” Opioids were available to women in tonic form 100 years ago and sold as “Mother’s Little Helper.” Women still tend to use prescription drugs as a coping mechanism. Teenagers get the drugs from their parent’s medicine cabinet. Pregnant girls have the highest rate of use, and the rate of depression is higher in opioid users. Also, the patterns are telescoping: users are more likely to progress from experiment to abuse and dependence in a shorter period of time; 3 years for women vs. 6 years for men.

RI has initiated a prescription drug monitoring task force, with the goal of creating a database to track all prescription medications prescribed and used, so that they can identify misusers earlier and intervene before they become addicted.

RI Medicaid has 175,000 members, nearly one-fifth of the population. Women with chronic pain use twice the number of services as men, at double the monthly cost. (Medicaid: Men $1200 average; women $2400).

Methadone has a much longer half-life than originally thought. It should be used with caution, especially when other opioids are prescribed.

Roadmap to Care

Allison Croke, MHA, introduced the “Communities of Care” program begun 2 years ago by RI Medicaid. This targeted intervention provides short-term case management, using an interdisciplinary team, for people who have used the ER 4 or more times in a 12-month period where chronic pain has been the significant driver.

The integrated treatment plan includes a pain management program, a team of supporters including a peer navigator, and self-responsibility combined with complementary care. Holistic nurses who are trained in outreach meet with the patient to develop their treatment plan. In addition to medication, the program supports the patient’s well-being with both physical and behavioral healthcare, chiropractic treatments, acupuncture and massage.

In Your Practice

Michael Maher, MD acknowledged that managing patients with chronic non-malignant pain is very difficult, and that “we are under-educated” about the drugs we are using. Originally there were no standards for how to manage patients on pain medication. Today standards include RI Department of Health Guidelines which require a physician and patient relationship, patient history and a physical exam.

Dr. Maher added strong suggestions for improved care that include determining the functional impact of the patient’s pain, and screening for substance use disorders. Other recommendations include:

• Patient responsibility contract
• History from pharmacies of patient drug use
• On-going screen for drug misuse, abuse or diversion,
• Urine screening
• Scheduled meetings

Providers should recognize that treating pain is not just about bringing down the pain number; it is about improving the patient’s functionality. Can they go out and take care of themselves in a better way? Do they meet functional improvement goals? Rather than just handing out the next month’s prescription, ask if this medication is helping. Because these are dangerous medications, “If they are not helping the patient, get them off it.”

The World Health Organization predicts that by 2020 the leading disability in women worldwide will be depression. Women are at higher risk for both depression and suicide. At present, twice as many women as men (17%) will have a major depressive disorder in their lifetime. They have more severe symptoms, including self-criticism, guilt, worthlessness, anxiety, low energy and interpersonal sensitivity. (Carpenter)

Suicide is an escape behavior; a way to get out of seemingly unmanageable problems, including the pain of anxiety, guilt, hopelessness, loss of status, job and money, and/or relationship separation or conflict. Both disorders reflect the additional risk factors for women: intimate partner violence, eating disorders and hormonal changes. (Jordan)

Patients with multiple physical and behavioral health problems often are treated by providers, who “don’t talk to each other and make the patient way worse,” according to Jane Hayward, CEO and President of the Community Health Center Association. When chronic pain, substance abuse and chronic mental health issues are combined in one patient, the costs of treatment are 7 times higher than with just one situation. People with chronic mental illness are likely to die 25 years sooner than the average.

In many practices, including Community Health Centers, legal precedents and payor policies lag behind new integrated care solutions, and can inhibit effective patient treatment. This is a compelling issue now because of the epidemic issues around depression and prescription drug misuse, increase in illicit drug misuse and the unmet need for affordable, accessible mental health professionals.

Also of note: no one system of care is right for every setting. Effective systems of integrated care must be culturally specific. “If you’ve seen one health center, you’ve seen one health center.” (Hayward)

Good to Know

Depression is linked to multiple factors: aging, genes, hormone changes, exposure to toxins, infectious pathogens, injury and inflammation. Early childhood stress is a powerful contributor, including low socioeconomic class. Evidence of abuse and neglect is visible in brain tissue; abuse and neglect leaves a biological scar, which indicates risk of chronic inflammatory illnesses, depression and suicide.

Conditions linked to depression include diabetes, obesity, smoking, alcohol and a sedentary lifestyle. These co-existing conditions should be treated together. (Carpenter)

Bullying often precedes sexual violence and suicidal ideation. Students who are bullied at school are at higher risk of suicide. Men are exposed to more physical violence; women to more sexual abuse. (Perez)

Suicide is like having a glass already filled to the brim; just one more drop of agitation from panic, anger, helplessness—and in that moment the scale is tipped towards self-harm. It is the ultimate expression of hopelessness: “There is no answer for me and I’m giving up.” (Jordan)

Roadmap to Care

Improved care from the Community Health perspective means increasing better outcomes and decreasing costs. Many patients require a level of complex care no one person can provide. Some basic principles for integrated care include

• Patient-aligned financial incentives that allow providers to do what they do best
• Real-time patient information sharing
• Multi-discipline care teams
• Networks of care

Rapid Access RI demonstrates one approach—an urgent care center designed to divert people from expensive and excessive ER use. The Providence Center is seeing good outcomes in their intersection of primary care and behavioral health care. The challenge remains: continue to look for ways to integrate disciplines and overcome legal and policy barriers, because “We forget that we need to focus on systems of care, not systems of silos.” (Hayward)

In Your Practice

When the potential for depression or suicide appears, learn as much as possible about the patient’s history of trauma and functional impairment. Initial screening questions are listed on the Pocket Cards created for this workshop: Screening for Depression which includes the patient self-screening form (PHQ-9), and the series of suicide risk assessment questions known by the mnemonic IS PATH WARM? The SAFE-T card details Risk Factors, Protective Factors, Suicide Inquiry and recommended Interventions.

Other questions recommended at the workshop include:

• Have you ever had a period in your life when you didn’t care whether you lived or not?
• How will you behave differently when your depression is better? What is the end point? How will you know?

Consider how to move from silos of care to integrated systems of care, where the approaches of PCP’s and therapists come together to create:

o   Improved physical health, including nutrition (i.e. vitamin D for depression) and exercise to change sedentary lifestyle.

o   Behavioral health care including sessions to raise hope and self-esteem, internalize qualities of maternal warmth and assume more self-responsibility.

o   Social health including support groups for depression and suicide survivors, peer navigators and an on-going care team.

o   Complementary activities including massage, chiropractic treatments, acupuncture for pain and improved energy, and light therapy to relieve depression.

“We have to understand that by not addressing these socioeconomic issues, we’re going to spend more money on our health and suffer worse morbidity and mortality. By not paying for it now, we’re paying for it later in terms of lost health and lives.” Tracey Cohen, MD, Neighborhood Health Plan of RI

Research shows that the social circumstances in which we are born, live and work – our jobs, schools, built space, transportation, even the quality of civic life – get under the skin, influencing our behaviors, access to resources, chronic stress levels and ultimately increasing or decreasing our chances for health.

Racial and ethnic health inequities don’t just reflect income. More African American, Native American, Latino and Pacific Islanders are in poor or fair health than whites at practically every income level.

“Recognizing this, RI payors are driving delivery system change by creating, providing, or paying for services which are designed to bridge socioeconomic barriers.” Renee Rulin, MD, MPH, RI, Medical Director, Medicaid/United Health Care

“Right now we’re in a period of total disruption of the healthcare system. The Affordable Care Act will be disruptive, but the biggest disruption will come from the shift to electronic medical records, which will completely flip how healthcare is delivered, and how our socioeconomic stressors are resolved.

“Primary care provider systems and practices will be increasingly encouraged by payors to offer a more holistic range of services, so private practices look more like community health centers and a fuller range of socioeconomic stressors can be managed from one place.

“We will see health insurance carriers responding to what health consumers want as opposed to what employers want and as opposed to what providers offer. As a new consumer based healthcare system evolves, there is an immediate opportunity to be part of the conversation about what plans and payment models consumers want to have and what provider services are most effective.” Christine Fergueson, Director, RI Health Insurance Exchange

“Now is the time to engage (in developing criteria for these new models of payment),” as Christy Ferguson said, “I want you to come to me and say ‘this is what I want.’ ”

Good to Know

“Many people in RI are underserved because of RI’s role as a safe haven for immigrants and undocumented folks. We need more data in order to formulate new policies to better serve this population.” Mary Reich Cooper, MD, JD Co Chair, Women’s Health Council

Defining Measures

Starting in 1990, keynote speaker Michelle Berlin, MD, MPH, began to partner with the National Women’s Law Center (NWLC) and NIH to look at creating data collection on women’s health disparities and inequities, so that better policies could be promoted. She helped to define 26 health status indicators that are now used nationally and state-by-state to evaluate the status of women’s healthcare delivery. Divided into four categories, the units of measure are collected in every state across a consistent continuum of socioeconomic indicators that assess:

1. Women’s access to health care services

2. Addressing both wellness and prevention

3. Key health conditions, diseases and causes of death

4. Living in a healthy community

The results show that, as a country, our national grade has been unsatisfactory.

Click here for slides showing where RI meets the grade and where we need to improve. Michelle Berlin, MD, MPH, Oregon Health & Science University

Why Women Are More at Risk in RI

Rhode Island’s cost of living is 2.5 times above the poverty level. Assistance from RI Works is 65% below the federal poverty level, and 44,000 women are without health coverage.

Poor RI women are no longer on the policy agenda to increase their benefits because there is such a lack of respect among legislators for the single mother population. The ACA will provide more insurance to all Rhode Islanders including women through the new Health Benefits Exchange. We must make sure it is affordable. Linda Katz, JD, Executive Director, Economic Progress Institute

A high percentage of new mothers, especially with premature babies, have significant social and environmental stressors. They suffer from a combination of depression, domestic violence and substance abuse. Rates of mental health issues in mothers have gone up 64% as home situations continue to worsen.Betty Vohr, MD, Women And Infants Hospital

Health Payment Reform’s Triple Aim

1. Improve the patient experience
2. Improve health of the population
3. Reduce per capita cost of health

RI Medicaid is evolving from fee for service payment to value-purchasing with managed care organizations. The new goal is to pay for what is important to the patient, and to wrap a better delivery system around member practices. Renee Rulin, MD, MPH

Blue Cross Blue Shield of RI is supporting the Patient Centered Medical Home model, encouraging the development of a care team within practices and having staff work to the top of their licensure. Andrea Galgay, MBA

Neighborhood Health Plan of RI focuses on care across the socioeconomic spectrum because “the ROI is better when the whole person is considered.”Tracey Cohen, MD

Roadmaps to Innovative Care

Providence Community Health Centers We “crosswalk them.” Working with underserved populations, the Health Center decreases the barriers to care and helps patients understand their own disease process combined with their mental health issues. Patients develop their own multi-part plan and then are helped to get to the right resource when they need it.  Angela Reda, RN, Providence Community Health Centers

Health Leads goal is a healthcare system that addresses all of the patient’s basic resource needs as a standard part of quality care. Health Leads physicians, currently at Hasbro, write prescriptions for food, childcare, employment, job training, housing, and then walk patients over to the volunteer teams who follow the patient until their needs are met. Health Leads offers systemic deep integration of a practical solution for resolving socioeconomic determinants to health. Sonia Sarkar, MPH, Health Leads

Patient Centered Medical Home programs develop a patient care team within medical practices where all staff work to the top of their licensure and the whole patient is treated. The focus is on proactive care, like planning to complete tests and labs prior to patient visit with PCP. Patient engagement is the key. Andrea Galgay, MBA, Blue Cross & Blue Shield Of RI

Partnering with Parents Complex social environments contribute to the greatest risk of infant rehospitalizations. We’ve shown that increased parental support and education reduces infant rehospitalizations by 60% and since the average cost of rehospitalization is $22,000, this kind of intervention can have a significant impact on health care costs. Betty Vohr, MD, Women & Infants Hospital

In Your Practice

Many private practices don’t have the facilities to partner with Medical Home models or access to all the stakeholders needed to care for vulnerable families.

Right now, payors like Blue Cross Blue Shield, United Health Care, RI Neighborhood Health and developers of the new Health Insurance Exchange are actively seeking ways to wrap a better health care package around your practice. Let them know what you and your patients want.

Suggestions for improving access to care and a more holistic approach can include:

• Opening morning and evening after hours and on weekends to improve access for working parents and single mothers.
• More proactive service, like arranging to have lab tests completed prior to the PCP visit.
• Empowering a care team to offer more comprehensive care, because the results are significantly better when the whole person is considered.
• Most local insurers will now pay for adding Nurse Case Managers and Peer Navigators who connect all the dots for patients and pay attention to how they are living.
• Provide home visits
• Provide a training curriculum before taking child home; manage infant’s early care; give a new mother lots of assurance.
• Connect families with resources in the community, include housing and other environmental issues; add a Family/Parent Resource Counselor.
• Treat the whole family. Take a whole team approach.
• Provide contraceptive counseling to help women make better choices; one key question to ask at every patient encounter: “Do you want to become pregnant in the next year?”

Conference Survey Summary shows what percentage of conference attendees belong to each healthcare provider category.

The Affordable Care Act: A Quick Guide for Physicians  explains ACA’s key provisions that impact physicians and patients.

“We, as providers, have to be all about making the choices right for teens; not with what we think is right, but with resources and voices that support the choices they’re trying to make, and have already made.”

With these words, Mary Reich Cooper, MD, JD, Co-chair Women’s Health Council of RI, summarized the presentations and panel discussions at the Council’s fourth Critical Workshop Training.

New Ideas in Adolescent Girls’ Healthcare begin with a “Strengths-Based” approach that engenders trust, safety and better choices.

All too often teens don’t feel safe telling their truths to their parents, or at school, or to their doctors. So they avoid getting the medical help or counseling they need, until they face a daunting problem.

“Rather than seeing teens at risk,” advised Keynote speaker Patricia Flanagan, MD, “instead see youth at promise.” Use knowledge of teenage girls’ developmental stages to help them build on their strengths, by praising the skills they have mastered and effective contributions they have made.

As one teen panelist recommended, “Be open with teens. Make it safe, because in reality teens want someone safe to talk with about what they are facing.”

Good to Know

What is needed in many situations is a closer relationship between pediatrics and psychology, so that a teen who is struggling with addiction, abuse, pregnancy and/or sexual identity is referred to a professional who can provide the counseling and resources she needs—and provide support for her choices.

Behavior Patterns While adolescents are generally healthy, they have high rates of STD’s, and the highest growth in HIV (18-25 group). 23% of adolescents have high glucose or other pre-diabetic signs. Early substance and alcohol abuse puts adolescents at greater risk for dependency in later years. It appears that when these patterns are set in adolescent years, it signals poorly for their health as adults.

Brain Patterns Adolescents experience a non-linear growth of their pre-frontal cortex during their teen years. In their developing brain, neuronal growth expands, followed by a pruning process. So with this changing mental environment, they need help making good choices, seeing alternative solutions, understanding nuanced social cues and suspending their own beliefs long enough to hear someone else’s story.

Protective Patterns Research proves that the protective effects of family are long-lasting. Teens who feel loved and accepted no matter what survive better, and thrive. Family can be found in many places. Helping a teen find the family she wants and needs builds resilience in her life, so she can grow into a strong adult with the capacity and resources to care for herself and her children.

Roadmap to Care

Each of the panels in this workshop was comprised of a provider and a teenager who has shown exceptional resiliency in managing one of the following challenges. The spectrum of parental care the teens experienced ranged from strong support, to modeling addiction and recovery, to outright abuse and rejection.

Teen Pregnancy is a community issue. Providers need to promote pregnancy prevention and also embrace teens who are already pregnant or mothers, so they do not give up their dreams.

“I was so afraid to tell my mom I was pregnant, but getting a calm response from her has helped me a lot.” This teen did not want to drop out of school and give up her dreams. With the help of a supportive family, school and the baby’s father, she has learned how to manage motherhood, her education and now a job. “It’s a lot, but we’re learning how to manage it all.”

For a school project, she created a workshop that gave students the hard facts about being a teenage mom, including the day-to-day costs of infant care products, and details about the real demands motherhood makes.

Her recommendations: Provide emotional support by repeating “You can do it!” Schools can provide day care and help new moms keep up. This teen’s teacher brought school-work to her home so she could study every day after the birth and still graduate with her class.

Substance Abuse In addictive families, the priority is to keep the child safe, often by helping the parent address their own health needs.

This teen panelist’s stepfather was addicted to drugs; her mother to alcohol. She drank because she saw her mom do it. ‘I didn’t like the taste, but I liked how it made me feel. Happier and more energetic!” She didn’t have anyone to talk to about it, (she didn’t want to disappoint her mother), until she went to an AA meeting with her stepfather. “AA was a powerful reality check” and gave her the safe environment she was looking for. She is now sober, and both parents are in recovery.

She says: “Teens want to talk about what’s happening with them. They will, if it is safe.”

Sexual Identity Sex is not a teen thing, or a bad thing. The message should be to do it in a way that’s right for the individual

Teen: “I knew at the age of 10 that I was gay, but I never had anyone safe to talk to about it.” She didn’t trust her doctor because of emotional and sexual abuse at home. Her family pressured her to “get over it” When she finally found a gay foster home, she was encouraged to openly acknowledge her sexual identity. At school, a Gay-Straight Alliance teacher helped her deal with students who didn’t like her and attacked the way she dressed. “I’ve learned that if people don’t accept you for who you are, they are not your friends. Fortunately, I have broad shoulders that have helped me deal with the abuse.”

Her advice to providers: ‘Tell them you’re there for them, and that you support them.”

In Your Practice

At puberty, psychosocial screening is as important as the physical exam. For help screening teenage girls, download the Adolescent Girl’s Health Pocket Card, which suggests questions to ask and resiliency skills to praise.

Suggestions:

1. See her alone. Ask her parent to consider you an ally. What the teen tells you is confidential unless there is a safety issue involved that the parent needs to know about.

2. Set manageable goals both you and the teen can agree on.

3. Build a scaffolding of support by helping her understand:

• Mastery: Determine what she is good at
• Relationships: Who are her friends; who does she depend on; what support system does she have in place
• Independent decision making: Where has she made her own choices
• Generosity: Where has she shown signs of caring for others

4. Acknowledge and support high aspirations. For example, the teen mother who determined that she did not want to be “just a statistic” (meaning a high-school drop out) because of her baby. She was committed to a college education and more. These kinds of aspirations need support from parents, doctors and school officials.

5. Consider how to make the time and place of meetings and screenings more accessible to teen schedules, especially If she is a teen mom without a good support system, or struggles with an addiction in a family where a parent is also addicted, or is an LGBTQQ teen whose family does not accept her identity.

6. Give her your card. New technology to consider: PING MD, whereby teen can text her provider, communicate in the way she is most comfortable, and still be protected by HIPPA standards.

7. Family Acceptance Projects teach parents to accept their children no matter what.

Tobacco Control for Parents and Providers

In a subsequent meeting, Lisa Carnevale, Interim Director of the Rhode Island Tobacco Control Network, warned that 13.3% of RI youth are using tobacco. The tobacco companies are relentless at creating addictive tobacco products that look like colorful candies, and which are readily accessible at convenience stores around the state. Without a close look, it’s hard to tell that these are nicotine-based products. Kids become loyal consumers and help to keep these stores profitable.

Carnevale advised: “This is not your grandmother’s tobacco. Parents should check the ingredients of any new product their child brings home…it just might contain nicotine!”

Clinicians are needed to talk to policy-makers at the State House about the considerable physical risks these products represent.

Contact Lisa Carnevale at 401 533 5175, or go to www.ritcn.org.

Intimate Partner Violence (IPV) is defined as a pattern of coercive behaviors by someone involved in an intimate relationship with a victim. It is an on-going interplay of excessive power, control and victimization that ripples through family generations, work environments, social relationships, communities and governments.

The place women ought to feel the most safe, i.e., home, is not. Children who witness abuse face developmental delays and poor school performance (whether they have been abused or not). Because of denial and the fear of asking for help, or fear of harm to her children and/or pets, or fear that she’ll lose her children, it often takes six police interventions before a woman will seek safety. And because there are many layers of barriers to leaving a relationship (economic, cultural, habit, isolation, shame), women seldom admit their abuse or seek help. But the more frequent the abuse, the higher the risk of damage. If the woman doesn’t make a change, abuse becomes increasingly lethal.

Good to Know

Most abuse is hidden. Bring it out into the open by asking if it is occurring, using matter-of-fact language at the initial and follow-up screenings. Encourage repeat visits, saying, ”I am concerned about you and would like to see you again soon.”

Abusers believe they are entitled to their behavior. They are not. Arrest is mandatory. The third arrest is an automatic felony.

Providers are unsure of what to say when abuse is revealed. Use Information Cards and have referral phone numbers handy. It only takes a few minutes to acknowledge the situation, give the needed contact information and provide life-changing hope.

Victims fear losing children to DCYF or abandoning pets to harm. The Safe Families Collaboration Project requires absolute clarity about the risk to mother and child before reports to DCYF can be substantiated and acted upon. The Safe Pet Program provides immediate shelter for pets.

Roadmap to Care

While there may be many layers of barriers to leaving an abusive relationship, there are also many layers of support provided by medical, legal and community resources. Often all that’s needed to give a victim hope is empathy, recognition and the phone number of a hotline or resource center, so she knows there is a path to safety. It can help her to know that police will intervene, get her to safety and arrest the abuser, and that she has up to three years to file a police report.

Steps on the path include:

1.      Doctor’s office or ER These providers are uniquely placed to identify IPV at earliest stages and intervene with referrals to hotlines, community resource centers, police and court advocates.

2.     Hotlines Operated 24/7, trained responders provide an immediate lifeline to help, resource centers and police intervention.

3.     Resource Centers In RI, Day One provides immediate response to trauma and assault. Resource Centers around the state will always find shelter and a bed for a woman (and her children) who seek immediate safety.

4.     Police Special Victims Unit 401 243 6236. Providers have great influence on directing victims to call law enforcement, whose intervention is often vital in breaking cycles of violence. Police help the victim get to safety or medical treatment, and must by law arrest the perpetrator (the abuser or person who has the most power in the relationship.)

5.     Advocates These trained professionals advocate for women through the legal system and court process, i.e., how to obtain a restraining order or press charges. Advocates work from police stations and are available in every Rhode Island city and town.

In Your Practice

Because stopping the lethality of abuse begins with identifying it early, recognize the critical role that providers play. Changes at the policy level in hospitals, clinics and private practices make a difference. These are the steps recommended by the Women & Infants Hospital’s Domestic Violence Team:

• Commit as a practice team or hospital to improving the data around Intimate Partner Violence.
• Create a team to develop IPV policies, materials and training.
• Establish and review IPV assessment policies and language with staff.
• Make exam rooms safe, i.e., establish hospital or practice policy against having more than one person in the exam room.
• Place posters and brochures in waiting rooms, i.e. “You don’t have to suffer abuse. It is against the law. We can help.”
• Use everyday language when asking about abuse, i.e., “This is something I talk about with all my patients (because it is so prevalent).”
• Have a knowledgeable staff person dedicated to working with patients who reveal abuse.
• Establish strong links with community resource organizations.
• Track results.

Women are more susceptible to the harm of smoking and second-hand smoke than men. The fastest growing segment of the smoking population is young women. Smoking has a negative impact on 40 different physiological functions.

Meanwhile, the tobacco industry continues to aggressively market colorful candy-flavored nicotine products to young people. And funding for smoking cessation programs has been cut.

Fortunately, the recommendation by a provider to quit smoking increases the quit rate by 30%, especially when the right words are used, and counseling with medication is recommended.
More information: RI Tobacco Control Network

Good to Know

New tobacco screening measures will become mandatory in the next few years.

Government and community health policies aggressively seek to make tobacco use less normal, less available, more expensive and considered an environmental pollutant.

70& of smokers would like to quit. Only 15% are offered help.

Stats show providers are less likely to make a smoking diagnosis or order spirometry in women.

Women will quit smoking for the health of their unborn child. Then start again, not knowing that smoking contributes to post-natal morbidity.

A non-smoker who lives with a smoker has a 20% increased risk of disease.

Acupuncture reduces addiction in patients who are willing to quit, at the same rate of effectiveness as medicine and counseling.

Roadmap to Care

Each of the following interventions doubles the likelihood of quitting:

• Physician’s recommendation

• Counseling longer than 10 minutes

• Cessation Medication beginning with the patch

A study of 4000 smokers in RI showed that 42% don’t consider quitting an option, and another 40% aren’t ready to quit.

Assess their motivational levels by asking:

• “On a scale of 1 -10, how motivated are you to quit smoking right now?”
• “What makes you not a 1 or a 2?”
• “What will it take for you to get up to an 8 or 9?”
• “What would it take to make you more motivated?

When they’re ready to quit, prescribe cessation medication (patch, gum, lozenge, inhaler, nicotine spray, buproprion, varenicline) and refer them toQuitWorks–RI for cessation counseling.

In Your Practice

The combination of counseling and medication have the highest quit rate, but only 6% of smokers take advantage of this combination.

To make the right thing to do the easiest thing to do in your practice:

• Screen for tobacco use
• Recommend quitting
• Offer cessation medication
• Encourage counseling
• Follow-up

Remember that lecturing, labeling and statistics reduce motivation to quit. One way to increase motivation is to “develop a discrepancy.” Change is more likely to occur when a behavior is seen to be conflicting with important goals or values.

Step 1: Discover what is most important to the person (a value, relationship, goal or hobby)

Step 2: Explore the reasons why the person smokes

Step 3: Develop discrepancy by asking:

• How does continuing to smoke move you closer to what is most important to you?
• How does continuing to smoke move you further from getting what is most important to you?
• What do you make of this difference?

“Public policies sustain socioeconomic stressors. We create risk through our policies, and we have the power to change these policies.”
ANA NOVAIS, RI DEPARTMENT OF PUBLIC HEALTH

In the 2013 Women’s Health Council Survey on Socioeconomic Stressors, we asked our members “What are the biggest socioeconomic gaps that impede your vulnerable population from accessing health care?”137 doctors, nurses and social workers completed the survey. Topping the list of their responses by a significant margin were Incomeand Unemployment, followed in ranking by Transportation, Education, Housing, Language and Food Insecurity.

In our April workshop, we learned that poverty is associated with higher risk for many diseases. Poor housing affects both physical and mental health; and a lower education predicts poorer health outcomes as well as a shorter life expectancy. Presenters and panelists came together from the provider, payor and policy maker sectors to describe the needs they see and the innovative solutions they are implementing as care providers across many dimensions in Rhode Island.

Perhaps the most important plea was “How do we all work together and avoid redundancy? We still have the habit of being in a silo; we need to find a better way to coordinate care across the state.”  Lauren Morton,  Blue Cross Blue Shield of RI.  Barriers to women’s mental health continue, as it is very hard to find short-term care for women who are dual diagnosed and homeless, and also struggle with mental health issues. Psychiatry has to be at the table.

Good to Know

Two districts in Providence are part of a pilot program from Evidence2Success, which is a new strategic process to improve outcomes for all children by improving risk and protection factors at the community level.  “Addressing just one risk can impact many outcomes, so we look for the most effective evidence-based solutions and help to implement them.” Justin Milner, Evidence2Success

“This program brings public health right into the educational system, with outcomes for kids that improve their education as well as emotional well-being, behaviors, positive relationships and physical health.  What is really new is the mechanism for measurement and level of granularity we can get to in the most difficult areas where kids need to be buffered the most.” Carrie Bridges, Providence Public School System

RI has a history of successful public health efforts in reducing exposure and anti-tobacco messaging and is now far below national averages as a result. So there is a commitment in this state to redirect funds towards programs that are proven to be the most effective in reducing risk and improving protective factors for youth.

Roadmaps to Innovative Care

Here’s a look at what panelists from this workshop are saying and doing to improve access to coordinated health care for their patient populations.

Suzanne McLaughlin, MD at RI Hospital, talked about the host of challenges patients face before they get to the hospital; there is not enough opportunity to provide preventive care. Patients don’t have the reserves to sort out all the things they need, including behavioral health, nutrition and absence from work. She wants better parity of physical and mental health, both in provision and coverage. She is focused on promoting wellness from the first contact with a patient, saying “A healthy you is going to be a better mom, worker, and partner.”

Primary care for its homeless population has changed dramatically. From an outreach mobile van 7 years ago, now all primary care and internal medicine has been located inside the Crossroads building. Facing lack of transportation, it is difficult for the homeless population to find them. She recommends bringing more nurse care management into Community Health Centers.

Bernadette McDowell is a school nurse instructor and recommends increasing the number of school nurses who are responsible for student health for 6-8 hours every school day. Because of problems getting health insurance or access to primary care, the school nurse is often the only person they see. She recommends electronic medical records be made accessible to school nurses so student care is less fragmented.

Michelle Lupoli serves the Medicaid population via Neighborhood Health Care.

To better manage this vulnerable population, she hires community outreach workers to visit members homes and better understand their needs and conditions. Lack of transportation is a major barrier for members, so she hires pharmacists who do home visits. She also focuses on co-location of services at community health centers; and provides help with translations and childcare. She seconded the request for electronic medical records.

Nancy Harrison from United Healthcare also serves the Medicaid population and faces the same challenges the hospitals face in getting patients to engage in their own health care. She looks for new ways to deliver care to people who have long term health challenges, including behavioral health case managers or field managers, to do behind the scenes work that coordinates care for members on the street. She wants to give people hope that they can in fact navigate the healthcare system.

Lauren Morton described the Blue Cross Blue Shield of RI’s own Patient Centered Medical Home program, which focuses on using a nurse care manager to build trust between patient and provider and walk the patient through to the provider services. She is promoting electronic medical records to help patients get the most out of the system they can. Lauren asked how everyone might work together in a better way and avoid creating redundancy in the system. “We still have the habit of being in silos,” she cautioned. “ We need to understand all care management across the state, and find a better way to coordinate this care statewide.”

In Your Practice

Iris Tong, MD, described the new Women’s Medicine Collaborative (WMC) as a practice of integrated services, with multidisciplinary programs. The 11 specialties included are primary care, obstetric medicine, gastroenterology, behavioral medicine, plus clinical services and specialists, plus lifestyle medicine like yoga and massage.

The WMC goal is to inspire women to achieve health in mind, body and spirit. So the first shared vision for every staff member is to care for them self first, to respect each other’s work and to share common goals.  Staff and providers are encouraged to attend the Lunch and Learn sessions, join walking groups and take one of the Collaborative’s yoga or meditation classes.

This kind of intensive co-location makes a difference in providing coordinated integrated care. A checkout person can coordinate the next steps in patient care, on the spot, at checkout.

The nurses serve as case managers and coordinate care after ER, provide home care and facilitate referrals.

In the provider workspace, the Assistant and provider work side by side, so they know each other’s practices and preferences.

A patient navigator addresses the social needs of patients.

In this model of collaborative care, the various disciplines work together in real time to create and provide a team-activated plan of care.

Another new model of care recently introduced is the concept of “shared medical visits”, where multiple patients join in one room for a shared 90-minute medical visit with their doctor. Initially skeptical, providers have found that patients enjoy the sense of community and support that results. This is particularly effective with diabetes prevention, physical activity, nutrition improvement and stress reduction. Patients respond well to hearing about other people’s experiences, what they struggled with and how they have succeeded.

The next step for WMC is to build in the quality measures that will provide recognition that this model of co-located integrated care does in fact yield better healthcare results for patients, especially because it encourages proactive involvement in preventive care.

Survey Charts show survey responses from this year’s conference participants.

Additional Info on Survey Respondents

Resources Poster details opportunities and resources for women in RI.