# Presentation: 712586

## The Preconceptional Screening and Assessment Project: A Model to Address Behavioral Risk for Women of Reproductive Age in Primary Care

- Cindy Engler RN, MPH
- Beth Buxton-Carter, L.C.S.W.
- funded by the Maternal and Child Health Bureau

## Overview

- Goals and objectives
- Background and rationale
- Development of the tool
- Feedback: Behavioral Experts, Provider, Consumer
- Findings
- Next steps

## PSAP Goal: Improve the health of reproductive age women

- Tool
- Multiple risk assessment in single tool
- Brief
- Culturally appropriate
- Process
- Link screening to assessment, education and intervention
- Enhanced capacity
- Role of primary care provider
- Replicable in diverse settings
- Collaboration with Boston PHC and Mass DPH

**Notes:**
Our overall goal was to improve the health of reproductive age women – as an ultimate goal and as a strategy for reducing racial disparities in infant mortality.
We hoped to do this by developing a tool for screening for and identifying women at risk for depression, substance abuse and domestic violence when women weren’t already pregnant, and developing a process for further assessment and intervention. We also hoped to use the screening and assessment process as an opportunity for education, no matter what the woman’s status was vis-à-vis identified risks. We knew that the tool had to be brief. Had to be appropriate to a variety of cultures (providers couldn’t learn a separate tool for each group)
We focused on the primary care setting, recognizing its potential and actual role in caring for childbearing age women
	longitudinal relationship
	trusting relationship; proven role in behavior change such as smoking
	relationship regardless of pregnancy status
	not dependent on “special programs”
Also recognizing the real shortage of mental health, DV and s/a services – enhancing the role of the primary care provider to screen, educate, assess and initiate some type of intervention
Finally – we hoped to set the stage for this type of screening in health centers and primary care settings throughout Boston and Massachusetts

## Why screen for behavioral risks?

- 20.7% of women ages 18-30, and 21.4% of women ages 31-45 reported they felt sad/blue/depressed for > two weeks
- Twice as many Black women than White women reported poor mental health

## Why Screen?

- > 1in 5 adult women of reproductive age reported binge drinking w/in last month
- 26% (vs. 10%) female students who used alcohol w/in last month report abuse by date
- BIMR review – 25% reported being abused by their partners during pregnancy
- 44% reported repeated unintended pregnancies often preceded by abuse

## Why screen in Primary Care?

- Safety-net/pivotal point of health care
- Long term relationship
- Integrated with range of health-related activities
- Opportunities for early intervention

**Notes:**
There is a logic to screening in the primary care setting. Theoretically, the primary care setting is available to all, it is an entry point, a pivotal point. It isn’t a special program, a grant funded program that will go away.
Ideally, people have long term relationships with their PCP, relationships of trust and commitment
Many primary care sites – especially community health centers, have a demonstrated commitment and track record to serve their communities; they define and address problems from a population perspective
Primary care is, ideally, integrated with an individual’s full range of health care needs and behaviors

There are also new tools for addressing these problems in primary care settings – medications that are effective and safe for primary care providers, brief interventions...

## The sites

- Site 1
- 3 areas or practice – Adult, Adolescent and Women’s Health
- Latina, African-American, African, Non-Hispanic White
- Site 2
- Family practice model
- Latina, Southeast and South Asian, Eastern European, Brazilian, Cape Verdean
- Both sites
- Multiple screening tools in use
- Variation in screening practice among providers
- Challenges in linkage between screening, referrals and follow-up

## Tool Development/Feedback 

- Screening Working Group – “experts”
- Project Advisory Committee
- Focus Groups of consumers
- Provider Surveys and Meetings

## Feedback loop

-       **Screening working group **			**Community **
- 	Review existing tools			Focus groups
- 	Recommend questions, language		Project advisory cmte
- 				**Tool development**
**Funder/Grantees**	Review questions, language                **BPHC/DPH**
- 				Review feedback, results
-     **Patients**		Refine tool		**Providers**
-     Needs assessment				Assess values & needs
-     Focus groups					Trainings
- 							Feedback

**Notes:**
The screening working group consists of the project coordinator, representatives from the 2 sites, Mass DPH, BPHC, and consultant “experts” in domestic violence, substance abuse and depression

The Project Advisory Committee meets quarterly, average attendance 20-25 people – highly consistent group of attendees

## Challenges

- “Cultural differences”
- Consultants – providers
- DV-s/a-depression
- Buy-in
- Time constraints in primary care
- Capacity constraints in mental health
- Defining boundaries between screening, assessment and intervention
- “What do we do when someone screens positive??”

**Notes:**
Despite a high level of agreement on the overall goals of the project, and the spirit behind it, the process as been challenging.
Cultural differences – even though the majority of the consultants are themselves providers, there was a them and us relationship with the group members who were there to represent the health centers
Buy – in – time, capacity
Time constraints are real    
Mental health capacity is extremely limited. It became clear early on that the purpose of the project had to go beyond screening. That unless there was some degree of enhancement of the capacity of primary care providers to handle the preliminary assessment and intervention of the majority of the women who might screen in – there was no purpose served in simply flooding the system.
Even if there is a PAL – an assigned person at each site to help with referrals and feedback – that would not address the capacity issue sufficiently – and there would not be buy in by the mental health staff

## Provider Feedback 

- Time – as little as possible
- The provider should not do the screening
- Offends people from different cultural backgrounds
- We already do this – we don’t need a script
- We have no resources/capacity – don’t generate expectations that can’t be met
- Won’t work with all cultural groups

## PAC Feedback

- Routine screening is not being done
- There is a need to incorporate a _brief_ screening tool into routine primary care
- Trust/relationship is the key
- Routine screening for depression helps reduce stigma *“I want to be treated like a whole person”*

## PAC Feedback

- Ideal if provider can do the screening – strong message about importance
- Listen!  Providers tend to hear the answers they want
- Explore cultural context the behavior takes place in
- All patients should receive some education – regardless of screening results

## Focus Groups - General Feedback

- Agreement that questions  should be asked in primary care
- Communication skills and relationship between provider and patient are key
- Repeating same questions feels like “trick” to get positive response
- State upfront – *everyone* is asked, and stress confidentiality

## Focus Groups: Depression

- Depression questions are clear, easy to understand
- Non-judgmental: “When things in life are difficult”  – takes responsibility off of woman
- Opens a door, demonstrates interest
- Rarely asked about depression- “Don’t ask, won’t tell”

## Focus Groups: Alcohol/SA

- Fear: admitting problem, legal repercussions
- Need to ask in non-judgmental way
- Negative response to questions about family and friends
- Reframe as a common/direct medical question
- Don’t expect honest response

## Focus Groups: Domestic Violence

- Important to ask, and difficult to answer
- Don’t include too much...include everything
- Start with questions on safety/emotional abuse, end with questions on physical violence
- Questions about non-consensual sex with partner and control most controversial questions

## Findings

- Site 1
- Pilot began September 24, 2004
- Site 2
- Pilot began October 19, 2004
- Based on approximately 1600 Women

## Findings - depression

- Baseline rates (by chart review)
- 12%
- PSAP rates
- 23%  any risk of depression
- 14% Mild-moderate (score 3-5)
- 9%  Severe (score > 5)

## Findings –Substance use

- Baseline rates (by chart review)
- 3% substance or alcohol abuse
- PSAP rates
- 36% *any use*  English speaking
- 22% *any use* Spanish speaking

## Findings –Domestic Violence

- Baseline rates (by chart review)
- 2% history or current
- PSAP rates
- 14% history or current

## Any positive screen

- Site 1 		44.3%
- Site 2		52.4%
- Combined	46.3%

## Revised Tool

## Lessons learned:

- The tool
- It works
- It is acceptable to patients and community
- It presents challenges to providers
- The process of implementation
- Parallel to other areas of questioning and assessment in primary care
- Providers need efficient access to resources and referrals

**Notes:**
Pilot:Feedback from consumers and community members endorse the tool – the questions, the process, the fact that it is carried out by their providers, the fact that it asks about depression, domestic violence and substance use. “I want to be treated like a whole person” – integrating mind, spirit and body. They appreciate the lack of stigmatizing – problem-izing language. They appreciate that the questions are normalized
They endorse that all women should get some sort of education – despite her identified risk status.

Providers are going beyond screening and providing some level of intervention. But this is an important area for improvement

We have begun to investigate barriers to this stage of the process.
Readily available resources – pamphlets, information sheets, and referral sites (if not available on site) is a barrier that has been cited.

## What we learned...

- We’re on the right track
- Multiple risk screening is needed for reproductive age women
- Screening tools needed for all ages, genders in primary care
- Culture change in health practices take time
- Patients accept change more readily than providers
- Barriers must be continually assessed, acknowledged and addressed

**Notes:**
Although there is some overlap among the three areas of screening, there is no single screen that could stand alone – it seems that all 3 areas are necessary.

The tool has been piloted in a school based clinic with adolescents and seems to be acceptable and useful – though more work is needed
Anecdotally, we have learned that providers are beginning to use the questions to screen women who are not of childbearing age, to begin to explore concerns in the three domains in a targeted rather than a screening mode, and have been modified to screen men
There are a lot of forces competing for the attention and time of primary care providers. Buy in is not a one-time event – rather – a process – getting familiar with a tool, owning it, believing in it, realizing that it works and does something better than they were doing it
There is a gap between patients and providers –
Providers say “I’m already screening for these things”. Patients tell us they’re not. Providers say – this group would be offended if I ask these questions. Members of that group say – please ask us these questions
The process has to breathe – allow time for diffusion of experience and feedback with results

## Closing the Loop 

- Improve access to resources and referrals
- Staff training – bringing women’s voices/experiences into their training
- Pilot test role of case manager/advocate in all domains of screening
- Enhance systems of feedback to providers

**Notes:**
The final item is written in italics because that is our wish list. We hope to apply for funding to scale-up this project. We have the support of BPHC and MDPH. Our funders are happy with what we have developed. We would like to bring it to even more diverse settings – both by type of practice and by patient population.
Although we believe that there are important reasons why a primary care provider should be the one to ask the questions, we realize that this might not work, or might not be acceptable in every setting. So we would like to compare implementation and the rates of positive screens when the tool is delivered in various ways – self-administered, administered by an RN or medical assistant.
And, finally, we have to adapt the tool to a variety of electronic systems that are being used in primary care settings

## Mental Health Case Manager

- Supported by BHSI
- Supervised by Human Services/Mental Health
- Sits in Primary Care
- Performs screening prior to PE
- Provides education and resources for all women
- Regular communication with PCP

## Case Manager role

- Introduces self as primary care team member
- Normalization/education of behavioral health in primary care
- Offers brochure, business card
- Able to see patient same day or quick f/u appt. convenient for patient
- Tracks/follow up

## Screens

- 164 women screened
- 43% (70/164) screened positive for some behavioral risk
- 36% (55/164) positive risk for depression
-   3% (5/164) positive for suicidal ideation 26% (18/70) any etoh/substance use
- 14% (10/70) any domestic violence

## What works...

- Women are comfortable with case manager
- Personal connection with easy access
- Strong relationship with primary care and human services/mental health

## Challenges...

- Providers want to refer everyone who needs resources to the case manager
- Start up takes more time – new role
- More support needed for case manager than for primary care providers doing screening

## Sustainability

- OMH Funding: Increasing linguistic capacity
- Integrate into existing team and forms
- DPH role

## Acknowledgements

- Providers and staff at the three community health centers
- Members of the Project Advisory Committee
- All of the women in the community who participated in focus groups
- Dr. Barbara Gottlieb
- Massachusetts Department of Public Health
- Boston Healthy Start Initiative
- HRSA/Maternal and Child Health Bureau

## Contact Information:Cindy Engler, RN, MPHBoston Public Health Commission1010 Massachusetts AvenueBoston, MA. 02118 cengler@bphc.org