Integrating the Integrating the Life Course Model Life Course Model

into Case into Case Management Management

ServicesServicesNORTHEAST FLORIDA HEALTHY START NORTHEAST FLORIDA HEALTHY START COALITION, INC.COALITION, INC.

Presenters: Carol Brady, MAPresenters: Carol Brady, MA Faye Johnson, BSFaye Johnson, BS

July 15, 2009July 15, 2009

Snapshot of JacksonvilleSnapshot of Jacksonville

Infant mortality rate (2007): 9 deaths Infant mortality rate (2007): 9 deaths per 1,000 live births (2005 rate was per 1,000 live births (2005 rate was 11.6)11.6)

IM driven by disparitiesIM driven by disparities 42% of births to Blacks & other nonwhites42% of births to Blacks & other nonwhites Blacks historically have poorer outcomes Blacks historically have poorer outcomes

in Jax than other urban areas of statein Jax than other urban areas of state IM rate 2x higher than White rateIM rate 2x higher than White rate

The Magnolia ProjectThe Magnolia Project

Focus on disparities in birth outcomes Focus on disparities in birth outcomes Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR) Fetal & Infant Mortality Review (FIMR)Fetal & Infant Mortality Review (FIMR) Findings used to develop the Magnolia Findings used to develop the Magnolia

ProjectProject Adaptation of state, federal Healthy Start Adaptation of state, federal Healthy Start

models to address health of high-risk models to address health of high-risk women before and between pregnancieswomen before and between pregnancies

The Magnolia ProjectThe Magnolia Project

BenefitsBenefits Addressed gap in women’s health careAddressed gap in women’s health care Linkage to national preconception health Linkage to national preconception health

movement (CDC)movement (CDC) Promising practice, long-term impact on Promising practice, long-term impact on

outcomesoutcomes LimitationsLimitations

Still an INDIVIDUAL interventionStill an INDIVIDUAL intervention ““Boom-a-rang” effect (dependency model?)Boom-a-rang” effect (dependency model?)

Beyond PreconceptionBeyond Preconception National MCH Life Course meeting National MCH Life Course meeting

(2008)(2008) Goal: to promote dissemination and use Goal: to promote dissemination and use

of life course approach to close black-of life course approach to close black-white gap in birth outcomeswhite gap in birth outcomes

Developed by Michael Lu, et al.Developed by Michael Lu, et al. Approach suggests a complex interplay of Approach suggests a complex interplay of

biological, behavioral, psychological and biological, behavioral, psychological and social protective factors contributes to social protective factors contributes to health outcomes across the span of a health outcomes across the span of a person’s life.person’s life.

Life Course PerspectiveLife Course Perspective

Rather than focusing on risks, Rather than focusing on risks, behaviors & services during behaviors & services during pregnancy, CUMULATIVE effects of pregnancy, CUMULATIVE effects of health, life events are examinedhealth, life events are examined

Health & socioeconomic status of Health & socioeconomic status of one generation directly affects the one generation directly affects the health status --- and health status --- and REPRODUCTIVE HEALTH CAPITAL REPRODUCTIVE HEALTH CAPITAL – of the next one.– of the next one.

Life Course PerspectiveLife Course Perspective Life-course model BROADENS the focus Life-course model BROADENS the focus

of MCH to include both health and social of MCH to include both health and social equity.equity.

Socioeconomic status, race and racism, Socioeconomic status, race and racism, health care, health status, stress, health care, health status, stress, nutrition and weight, and a range of nutrition and weight, and a range of other behaviors impact birth outcomes.other behaviors impact birth outcomes.

Factors impact racial, ethnic groups Factors impact racial, ethnic groups differently and may explain disparities differently and may explain disparities despite equal access to care during despite equal access to care during pregnancy.pregnancy.

Life Course PerspectiveLife Course Perspective Life course framework in MCH has Life course framework in MCH has

PROGRAMMATIC and POLICY PROGRAMMATIC and POLICY implications.implications.

Content of case management is expanded Content of case management is expanded (poverty, economic security, education)(poverty, economic security, education)

Services are organized and delivered in Services are organized and delivered in ways that build resiliency and social ways that build resiliency and social capital and reduce dependency (group capital and reduce dependency (group activities, self-care)activities, self-care)

Requires inter-disciplinary, inter-agency Requires inter-disciplinary, inter-agency collaboration to address complex needs collaboration to address complex needs

Life Course PerspectiveLife Course Perspective

Challenge: how to OPERATIONALIZE?Challenge: how to OPERATIONALIZE? Contra Costa Health Services: 12 Contra Costa Health Services: 12

point planpoint plan Goals: Goals:

Improve health care services for at-risk Improve health care services for at-risk populations, including communities of populations, including communities of color & low-income familiescolor & low-income families

Strengthen families & communitiesStrengthen families & communities Address social and economic inequities Address social and economic inequities

over the life courseover the life course

12 Point Plan12 Point Plan Improve Health Care Services Improve Health Care Services

Access to interconception care, Access to interconception care, preconception care, quality prenatal care, preconception care, quality prenatal care, access to health careaccess to health care

Strengthening Families & CommunitiesStrengthening Families & Communities Father involvement, service coordination, Father involvement, service coordination,

creation of reproductive health capital, creation of reproductive health capital, community building & urban renewalcommunity building & urban renewal

Address social, economic inequitiesAddress social, economic inequities Close education gap, reduce poverty, undo Close education gap, reduce poverty, undo

racism support working mothersracism support working mothers

Life Course PerspectiveLife Course Perspective

Challenge:Challenge: How to OPERATIONALIZE life course How to OPERATIONALIZE life course

approach into service deliveryapproach into service delivery Opportunity:Opportunity:

Change the way we deliver case Change the way we deliver case management services at the Magnolia management services at the Magnolia ProjectProject

Pilot projectPilot project

The Magnolia ProjectThe Magnolia ProjectCase Management has Case Management has

EvolvedEvolved Most case management models focus on Most case management models focus on

specific individual risk factors.specific individual risk factors. Risk factors may include family planning, Risk factors may include family planning,

sexuality transmitted diseases, substance sexuality transmitted diseases, substance abuse, smoking, and other risk associated abuse, smoking, and other risk associated with poor birth outcomes.with poor birth outcomes.

Case management focuses on risks that are Case management focuses on risks that are immediate (in crisis) and long-term.immediate (in crisis) and long-term.

Often case managers become the primary Often case managers become the primary support system for women.support system for women.

Why Change ? Why Change ?

To offer women a variety of service learning To offer women a variety of service learning that does more that focus on surface need.that does more that focus on surface need.

Opportunity to address the underlying social Opportunity to address the underlying social determinants that impact birth outcomes. determinants that impact birth outcomes. Such as; finances, education, poverty, Such as; finances, education, poverty, racism, family support and connectedness.racism, family support and connectedness.

Provide an opportunity so that women in Provide an opportunity so that women in case management develop support among case management develop support among each other once case management ends. each other once case management ends.

Life Course Perspective Life Course Perspective Pilot Pilot

Conducted a 6 month Integrated Life Conducted a 6 month Integrated Life Course Perspective case management pilotCourse Perspective case management pilot

Two levels of services offered to women Two levels of services offered to women enrolled in case managementenrolled in case management

Level 1 - Individual case management Level 1 - Individual case management involved women that entered the program involved women that entered the program and were in crisis which required one on and were in crisis which required one on one assistance.one assistance.

Level 2 – Group level intervention planned, Level 2 – Group level intervention planned, organized and delivered by the case organized and delivered by the case managers and one community partner. managers and one community partner.

What was DoneWhat was Done Case managers and the Women's Intervention Case managers and the Women's Intervention

Specialist were responsible for one component Specialist were responsible for one component within the three areas of focus in the Life within the three areas of focus in the Life Course Model.Course Model.

EducationEducation FinanceFinance Reproductive HealthReproductive Health Healthy Relationships Healthy Relationships

Responsibility included determining level Responsibility included determining level statusstatus

Facilitated bi-weekly group activities Facilitated bi-weekly group activities Identified additional group resources.Identified additional group resources. Managed existing caseloadManaged existing caseload

How How The Women’s Intervention Specialist The Women’s Intervention Specialist

completes “My Life’s Journey” completes “My Life’s Journey” (assessment) with all newly referred women(assessment) with all newly referred women

During the assessment the Women’s During the assessment the Women’s Intervention Specialist markets all Intervention Specialist markets all components of the program to include the components of the program to include the various group topics. various group topics.

Assigned to case manager based on the Assigned to case manager based on the assessment of life’s strengths and assessment of life’s strengths and challenges with the participant to challenges with the participant to determine level of need .determine level of need .

Outcomes of PilotOutcomes of Pilot

The group with the most participation The group with the most participation was the Financial Freedom Group was the Financial Freedom Group activity “War on Poverty” activity “War on Poverty”

Consisted of 3 six week group activities Consisted of 3 six week group activities with and average of 5-8 women.with and average of 5-8 women.

Several of the women formed bonds Several of the women formed bonds over the six week period.over the six week period.

Level of excitement leading up to the Level of excitement leading up to the next group. next group.

Increase in financial knowledge Increase in financial knowledge

Lessons LearnedLessons Learned Focused on several groups Focused on several groups

simultaneously with a new model. “Too simultaneously with a new model. “Too much too fast”!much too fast”!

Case mangers focused primarily on the Case mangers focused primarily on the new group activities opposed to the new group activities opposed to the entire Life Course Perspective Modelentire Life Course Perspective Model

Dual role for case managers proved to Dual role for case managers proved to be a challengebe a challenge

Need to clarify roles continuouslyNeed to clarify roles continuously Did not have an opportunity to evaluate Did not have an opportunity to evaluate

the Goal Attainment Scale during the the Goal Attainment Scale during the process. process.

What’s NextWhat’s Next

Fully and completely implement the Fully and completely implement the New Redesign to include lessons New Redesign to include lessons

learnedlearned

WHY ?WHY ?

Benefit of Integrating The Life Benefit of Integrating The Life Course Perspective into Case Course Perspective into Case

ManagementManagement The participants welcomed the change and The participants welcomed the change and

were excited during the group activity. were excited during the group activity. An opportunity to address the social An opportunity to address the social

determinants that influence poor birth determinants that influence poor birth outcomesoutcomes

Promoted inter-and independence while Promoted inter-and independence while building reproductive capital in the building reproductive capital in the community.community.

The approach can contribute to improved self The approach can contribute to improved self esteem among the women enrolled in case esteem among the women enrolled in case management.management.

More Benefits More Benefits

Participants developed support systems that Participants developed support systems that continued after case management services continued after case management services ended.ended.

Received a wealth of information and Received a wealth of information and training through numerous group activities training through numerous group activities and individual case management. Reinforce!and individual case management. Reinforce!

Participants will have an opportunity to take Participants will have an opportunity to take an active role in tracking progress in an active role in tracking progress in achieving goals included in their life plans achieving goals included in their life plans (GAS).(GAS).

New Case Management ModelNew Case Management Model

Women complete a “My Life’s Journey” Women complete a “My Life’s Journey” assessment and are assigned to Level 1 assessment and are assigned to Level 1 Individual Case Management.Individual Case Management.

Information gathered during the Information gathered during the assessment will fall in one or more assessment will fall in one or more areas in the Life Course Model. areas in the Life Course Model.

The case manager and the participant The case manager and the participant will develop a Life Course Plan from will develop a Life Course Plan from the information gathered during the the information gathered during the assessment based on areas in the Life assessment based on areas in the Life Course Model developed by Dr. Course Model developed by Dr. Michael Lu, MD. Michael Lu, MD.

The PlanThe Plan

The individual Life Course Plan is The individual Life Course Plan is participant- driven with established participant- driven with established goals and address needs in three areas:goals and address needs in three areas: Access to preventive health care Access to preventive health care and and

related risk reduction services that related risk reduction services that improve a woman’s chances for healthy improve a woman’s chances for healthy birth in the future. This includes basic birth in the future. This includes basic reproductive health services, such as GYN reproductive health services, such as GYN care and family planning, as well as care care and family planning, as well as care for chronic diseases like diabetes, for chronic diseases like diabetes, hypertension and obesityhypertension and obesity

Life Course Plan Life Course Plan Continued Areas Continued Areas

Family and Community support Family and Community support including activities that provide at-risk including activities that provide at-risk women with the skills to develop healthy women with the skills to develop healthy relationships and connectedness with relationships and connectedness with communities through civic engagement communities through civic engagement and participation.and participation.

Reduction of poverty and social Reduction of poverty and social inequities inequities that assist participants in that assist participants in completing their education, gaining job completing their education, gaining job skills, confronting discrimination and skills, confronting discrimination and racism, and developing financial literacy.racism, and developing financial literacy.

Developing The Life PlanDeveloping The Life Plan

Case manager assists in the development of the Case manager assists in the development of the participant-driven life plan through the use of 5 participant-driven life plan through the use of 5 questions specific to each of the three areas to questions specific to each of the three areas to identify a life plan.identify a life plan. Access to preventive health care/reproductive Access to preventive health care/reproductive

health.health.1. Do you hope to have (more) children?1. Do you hope to have (more) children?2. How many children do you hope to have2. How many children do you hope to have3. How long do you plan to wait until you (next) become 3. How long do you plan to wait until you (next) become pregnant.pregnant.4. What do you plan to do until you are ready to get 4. What do you plan to do until you are ready to get pregnantpregnant5. What can I do today to help you achieve your plan?5. What can I do today to help you achieve your plan?

Reproductive Plan Questions taken from a presentation by Merry-K Moos at theReproductive Plan Questions taken from a presentation by Merry-K Moos at thePreconception Health an Health Care Conference, October 2007.Preconception Health an Health Care Conference, October 2007.

Family and Community SupportFamily and Community Support 1. Who is your favorite family member?1. Who is your favorite family member?

2. How do you gain friendship with others?2. How do you gain friendship with others?3. What activities do you like?3. What activities do you like?4. Do you want to help others?4. Do you want to help others?5. How can I help you develop healthy 5. How can I help you develop healthy relationships?relationships?

The questions are merely examples but The questions are merely examples but necessarynecessary

in assisting participant in the development of a in assisting participant in the development of a LifeLife

Plan.Plan.

Group Level of ServiceGroup Level of Service Participants are enrolled in external group Participants are enrolled in external group

activities that are specific to their Life Plan.activities that are specific to their Life Plan. The groups are scheduled through external The groups are scheduled through external

resources relieving the case managers of the resources relieving the case managers of the responsibility.responsibility.

Case managers’ responsibilities include Case managers’ responsibilities include notifying management of any external notifying management of any external groups, assisting participants with access to groups, assisting participants with access to the activity and encouraging participationthe activity and encouraging participation

Body and Soul Reproductive Health Group is Body and Soul Reproductive Health Group is conducted at the Magnolia Project where conducted at the Magnolia Project where clinic services are provided. All participants clinic services are provided. All participants are encouraged to complete the reproductive are encouraged to complete the reproductive health group on site, facilitated by the Health health group on site, facilitated by the Health Educator. Educator.

Monitoring ProgressMonitoring Progress

Participants take an active role in Participants take an active role in monitoring their progress in monitoring their progress in achieving their goals included in achieving their goals included in their “life Plans.” their “life Plans.”

The Goal Attainment Scale (GAS) is The Goal Attainment Scale (GAS) is used to determine progress.used to determine progress.

Example of GAS ToolExample of GAS Tool

Simplified Simplified

Complete My Life’s Journey assessmentComplete My Life’s Journey assessment Assigned to my case manager Assigned to my case manager My Life Journey information falls within 3 My Life Journey information falls within 3

areas of the Life Plan Modelareas of the Life Plan Model Develop My Life Plan using 5 questionsDevelop My Life Plan using 5 questions Begin in individual case managementBegin in individual case management Attend group activities (level 2) ensuring Attend group activities (level 2) ensuring

that my plan has continuity.that my plan has continuity. Track My Life Plan Goals using a GAS Track My Life Plan Goals using a GAS

tool . tool .

The Life Plan Perspective The Life Plan Perspective

Change in approach = positive response Change in approach = positive response from participants, MOST stafffrom participants, MOST staff

Model has impacted the way we do businessModel has impacted the way we do business Use of life course framework in update of Use of life course framework in update of

Healthy Start Service Delivery PlanHealthy Start Service Delivery Plan New collaborations in economic self-sufficiency, New collaborations in economic self-sufficiency,

community developmentcommunity development How to incorporate in state HS case How to incorporate in state HS case

management??management??

Questions? Thank you!Questions? Thank you!