母親項目：通過遠程醫療為農村地區提供孕產婦外展服務.pdf

1、The MOTHeRS Project:Maternal Outreach through Telehealth for Rural SitesSy Atezaz Saeed,MD,MS,FACPsych,Professor and Chair EmeritusDepartment of Psychiatry and Behavioral MedicineFounder and Executive DirectorNorth Carolina Statewide Telepsychiatry Program(NC-STeP),andECU Center for Telepsychiatry a

2、nd e-Behavioral HealthWomen face significant challenges in accessing comprehensive,affordable,high-quality maternal and mental health care,especially in rural areas that are characterized by high unemployment,poverty,significant minority populations,and geographic barriers that complicate access to

3、care.The COVID-19 pandemic further intensified health disparities,especially in maternal health among expectant mothers in rural Eastern North Carolina.These mothers faced increased risks due to limited access to prenatal care for high-risk pregnancies,maternal-fetal medicine specialists,heightened

4、mental health issues,and the impact of social determinants of health.The MOTHeRS Project implemented a multidisciplinary telehealth service integrating maternal-fetal medicine specialists,diabetes educators,nutritionists,psychiatrists,and other health care professionals into rural obstetric clinics.

5、This model helped manage patients in clinics closer to their homes,minimized the need for travel,and brought specialized care directly to underserved communities.Implementation of telehealth services in this project reduced travel for high-risk patients by over 396,894 miles and facilitated 2,523 pa

6、tient visits,including behavioral health interventions.Moreover,the project addressed food insecurity by distributing medically-tailored food bags to high-risk pregnant women.Our experience highlights the importance of strengthening multidisciplinary care coordination,investing in human service prog

7、rams,and addressing workforce issues to enhance care delivery.Abstract1.Describe challenges women face in accessing comprehensive,affordable,high-quality maternal and mental health care,especially in rural areas.2.Identify multidisciplinary components of the MOTHeRS Project model and how they addres

8、sed challenges associated with access to evidence-based care in underserved communities.3.Describe how use of health technologies and telehealth can help with providing multidisciplinary health care to those who are currently underserved or who lack access to services.4.Describe how effective telehe

9、alth programs require robust multidisciplinary coordination to provide integrated care.5.List lessons learned from the MOTHeRS Project,including the challenges faced and how they were overcome.Learning ObjectivesSy Atezaz Saeed,MD,MS,FACPsych has no real or apparent conflicts of interest to reportTh

10、e Challenge East Carolina University(ECU),the safety net provider for 1.4 million people in Eastern North Carolina,is the only source for high-risk prenatal care in the region.Socioeconomic factors limit access due to transportation,adequate nutrition,and basic necessities for the maternal populatio

11、n.One in four of our mothers live in poverty;one in eight are uninsured.Poverty rate 17%compared to 14%for the state1 Child poverty rate 25%(over 30%in 8 of the counties in the region)1 15%of the population is food insecure,and many in the largely rural region have low access to a food store.2 For 1

12、8 of the counties in the region,70%or more of the births were to mothers with Medicaid.31.U.S.Census,American Community Survey 2016-2020.2.University of Wisconsin Population Health Institute.County Health Rankings.2022.https:/www.countyhealthrankings.org/explore-health-rankings.Accessed September 23

13、,2024.3.North Carolina State Center for Health Statistics.County Health Data Book.Births to Medicaid and WIC Mothers 2015-2019.The Challenge(continued)The Challenge(continued)Health care disparities in the 41 North Carolina counties along or east of the I95 corridor:premature mortality rate for the

14、region is 18%higher than for the state overall1 diabetes mortality is 29%higher,and the diabetes mortality rate for non-White females in the region is more than double the rate for White females in the state overall1 1.Health Systems Research and Development,Department of Public Health,East Carolina

15、 University.Trends and disparities in mortality in eastern North Carolina:total deaths,premature mortality and deaths for ten leading causes;1990-2019.March 2022.https:/hsrd.ecu.edu/wp-content/pv-uploads/sites/445/2022/04/ENC41_2019_Health_Indicators_FINAL_4.1.2022.pdf.Accessed September 23,2024 202

16、1 US maternal mortality rate=32.9 deaths/100,000 live births White women=26.6 deaths/100,000 live births Black women =69.9 deaths/100,000 live births For North Carolina,the rate was 44.According to CDC,over 80%of pregnancy-related deaths were determined to be preventable.BackgroundPregnancy-Related

17、Deaths:Data From Maternal Mortality Review Committees in 36 U.S.States,20172019.Available at:https:/www.cdc.gov/maternal-mortality/php/data-research/mmrc-2017-2019.html.Accessed October 10,2024.Racial Disparities in Maternal MortalityPregnancy-related mortality ratio by race-ethnicity:20172019 and 2

18、02011.Reproductive Health.Pregnancy Mortality Surveillance System.Centers for Disease Control and Prevention website.Accessed September 27,2024.https:/www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance/?CDC_AAref_Val=https:/www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy

19、-mortality-surveillance-system.htmNon-Hispanic Black and Non-Hispanic White Pregnancy-Related Mortality Ratios by Year,NC Residents 2001-2016NORTH CAROLINA Maternal Mortality Review Report.Available at https:/wicws.dph.ncdhhs.gov/docs/2014-16-MMRCReport_web.pdf.Accessed September 27,2024.Perinatal m

20、ental health conditions,such as anxiety and depression,are very common complications of pregnancy,affecting roughly 8%11%of all women during pregnancy and 6%12%in the postpartum period.1 Perinatal mental health conditions are more common for African Americans,and also for low-income women.1 1.Gaynes

21、 B,et al.Perinatal depression:prevalence,screening accuracy,and screening outcomes.Evid Rep Technol Assess(Summ).2005;(119):18.Role of Mental Health Pregnancy is commonly associated with changes in psychological functioning,often manifested as anxiety,ambivalence,mood changes,tiredness,and sleep dif

22、ficulties.Pregnant women may also have pre-existing mental health conditions,such as depression,bipolar disorder,panic disorder,post-traumatic stress disorder,or a substance use disorder.All this can affect mothers functioning which in turn may negatively affect growth and development of their child

23、ren.Role of Mental HealthFood insecurity during pregnancy is related to poor diet quality,excess weight gain,depression,anxiety,and poor infant outcomes.Interprofessional interventions,including addressing FI,are known to relieve stress and depression1-4.1.Laurenzi C,Field S,Honikman S.Food insecuri

24、ty,maternal mental health,and domestic violence:a call for a syndemic approach to research and interventions.Matern Child Health J.2020;24(4):401404.2.Dolatian M,Sharifi N,Mahmoodi Z.Relationship of socioeconomic status,psychosocial factors,and food insecurity with preterm labor:a longitudinal study

25、.Int J Reprod BioMed.2018;16(9):563570.3.Agusto et al.Household food insecurity associated with gestacional and neonatal outcomes:a systematic review.BMC Pregnancy Childbirth.2020;20(1):229.4.Modi V,Sastre L,Saeed S,et al.A MOTHeRS Perspective:Satisfaction of Tailored Food Bags for Food Insecure Pre

26、gnant Patients.Presented at Society for Public Health Educations 73rd Annual conference(digital experience),March 2022.Food Insecurity(FI)We started with the belief that where an expectant or new mother lives should not negatively impact her physical or mental wellbeing or that of her child.In July

27、2020,ECU expanded the North Carolina Statewide Telepsychiatry Program(NC-STeP)a statewide telepsychiatry program,to bring multidisciplinary care to four community-based rural primary care obstetric clinics.One Solution:Outreach through TelehealthWe utilized telehealth and the NC-STeP framework to de

28、velop and implement a new high-risk obstetric care model for our region.MethodsDeveloped in response to Session Law 2013-360.G.S.143B-139,4B Recodified as G.S.143B-139.4B(a)(1b)by Session Laws 2018-44,s.15.1,effective July 1,2018,expanding the scope of NC-STeP to community-based settings.17 Team-Bas

29、ed Care Primary care provider remains the driver Patient-Centered Collaboration Measurement-Based Treatment to Target Evidence-Based Care A team of 3 individuals deliver CoCM:Behavioral Health Care Manager Psychiatric Consultant Treating Practitioner Our MFM team covers the 29-county region in rural

30、 eastern North Carolina through its Regional Perinatal Clinic(RPC).We selected four obstetric practices that refer high-risk patients to the RPC and set up these clinics as our telemedicine sites.The sites were selected based on the:number of high-risk patients access to care challenges enthusiasm o

31、f the practices to participate in this programMethods Primary obstetrician Maternal fetal medicine(MFM)specialist Nurse navigator Registered dietician/Nutritionist Diabetes educator Psychiatrist Behavioral health managerMOTHeRS TeamThe MOTHeRS model helped manage patients in clinics closer to their

32、homes and minimized travel to the remote specialty clinics for high-risk patients:enhanced access to services helped reduce geographic health disparities enhanced patient convenience improved patient adherence to treatment Through a combination of telehealth and in-person visits,patients in the prac

33、tices were cared for by both an MFM specialist and their local obstetrician.All sites were provided equipment for telehealth services.Providers and staff were trained in use of the equipment and its integration with the Electronic Health Record(EHR).Methods(continued)This co-management model helped

34、create a patient-centered team approach to care delivery to improve patient experiences and a positive impact on maternal fetal health.MOTHeRS Model of Care The sites ultrasound machines were integrated with PACS(picture archiving and communication system)to enable the MFM specialist to see images r

35、emotely.Ultrasounds were conducted at the primary clinic location and transferred electronically along with other electronic health records prior to the MFM specialist visit.Where clinically appropriate,the general obstetrician at the rural sites referred high-risk patients to tele-consults with an

36、MFM specialist at ECU.Ultrasound and Integration with PACSScreening for Mental Health All patients were administered:9-question Patient Health Questionnaire(PHQ-9)7-question GAD-7 Patients who screened positive for a mental health condition were referred for a tele-consult with the BHM When clinical

37、ly indicated,referred for a consult with the telepsychiatrist,within the same clinic location.Screening for Food Insecurity(FI)All patients were screened for FI,using a validated,two-item tool.1 An affirmative response2 to at least one of two questions,asked in a clinical setting,is 97%sensitive and

38、 83%specific for FI:Within the past 12 months,we worried that our food would run out before we got money to buy more.Never Usually Sometimes Within the past 12 months,the food we bought just didnt last and we didnt have money to get more.Never Usually Sometimes1.Hager,E.R.et al.(2010).Development an

39、d Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity.Pediatrics,126(1),26-32.2.An affirmative response is“Usually”or“never”When indicated,patients were also referred for a tele-consult with a registered dietitian and a certified diabetes care and education specialist.Nutrit

40、ion and Diabetes Education/Care Those screened as food-insecure were offered a medically tailored food bag,nutrition education handouts,and links to existing community resources for emergency food.Essential nutrients contributing to a healthy pregnancy that are often under-consumed and not adequatel

41、y covered with a prenatal vitamin supplement were identified and included in the food bag.The details are available at:https:/thescholarship.ecu.edu/items/a576c263-3a71-4078-bc3d-8e40dae4d6f9.1-2 1.Smith B,Kolasa KM,Sastre LR,Craven K.MOTHeRS Project:Acceptability of a medically tailored food bag tr

42、eating food insecurity in high-risk pregnant patients.Poster presented at:SNEB 2021 Annual Conference;August 9,2021;Department of Family Medicine,East Carolina University,Greenville,NC.http:/ B,Kolasa KM,Craven K.Emergency Food Bag and Patient Education for the MOTHeRS Project.Presented at:ECU Famil

43、y Medicine Research Day;June 10,2021;Department of Family Medicine,East Carolina University,Greenville,NC.http:/ We contracted with a local Medical Food Pantry,experienced in purchasing and packing emergency food bags for a large medical system,to purchase foods,manage food storage,pack bags,and del

44、iver them to the rural practices.Handouts depicting healthy eating and food safety(in English and Spanish)along with eating for special diets such as gestational diabetes were designed and included with the bag contents.A training module for office staff on screening for food insecurity and basic nu

45、trition messages that should accompany the bags was developed and provided to office staff.Food Insecurity(FI)Methodology,Technical Report,and Bag Description:http:/ and Shopping Guide(English and Spanish):http:/ Safety(English and Spanish):http:/ and Spanish):http:/ Diabetes Pyramid(English and Spa

46、nish):http:/ to Materials on Food Insecurity(FI)Nurse navigator coordinated the process.Behavioral health manager coordinated the mental health carePrimary obstetrician remained the overall coordinator of care and the prescriber.Navigation and Coordination of Care Short supply of providers Challenge

47、s with recruiting MFM specialists,diabetes educators,and nurse navigators Dealing with turnover Scheduling adequate time blocks for both MFM specialists and obstetric nurse navigators Dealing with vacation,sick,medical leaves Challenges Telehealth visits with real time sonography may be the future o

48、f rural obstetrics but to make it a win/win/win for all stakeholders(patients,practices,and MFM specialists)requires partnering and coordination of resources more effectively.Partnering with an MFM group that has both the capacity and expertise to incorporate new methods of providing care is also es

49、sential.Developing a role for a Nurse Navigator for rural high risk obstetric patients is worth investigating.Lessons Learned The program was designed to use telehealth to integrate maternal/fetal medicine specialist visits into general OBGYN practices.The behavioral health component was not necessa

50、rily the main part of the program,but it proved to be the most utilized.The MFM component of the project was completed on March 31,2023,and all 4 practices opted to continue the tele-behavioral health component.Our experience suggests that OBGYN clinics may be good places for integrating behavioral

51、health services.Lessons Learned(continued)It is possible to create an emergency food bag that is acceptable to patients in rural eastern North Carolina and can meet the needs of under-consumed nutrients for pregnant women for 2 weeks,if the patient was the only person consuming the foods.Food bags w

52、ere heavy(between 20-30 pounds)and at times needed to be carried to the car for participants or split into two bags.Additional space for storage of bags was needed in some practices.Lessons Learned(continued)Lessons Learned(continued)The pandemic created shortages of some food items.We frequently ha

53、d to adjust the bag contents to utilize available foods with substitutions that would still meet the nutritional needs for this population.This required someone skilled in special nutrition needs of a pregnant woman and food composition to assess the changing landscape of available foods and make ch

54、anges.Working with an established food pantry skilled in working with patients who have medical conditions that require special diets was key to seamless delivery of the program.MOTHeRS Project provided a total of 2,428 patient visits,including:122 MFM specialist visits 116 visits with a diabetes ed

55、ucator/medical nutrition specialist 2,285 visits with behavioral health visits Saved 414,427 driving miles for patients and their families.Screened 41,229 patients for FI and distributed 888 food bags to those who screened positive for FI.Results and FindingsMOTHeRS Project ResultsAs of June 30,2024

56、Impact on Patient Access to CareNumber pf perinatal patients who received care(visits with MFM specialist)122*Impact on patient access(calculated as driving miles saved per MFM specialist visit and Diabetes educator/Medical Nutrition Specialist visit:Carteret36,784 driving miles saved*Number of pati

57、ent visits with Diabetes Educator or Medical Nutrition Therapist116Number of women served for mental health reasonsLCSW visits 1,675Psychiatrist visits 610Total Mental Health visits2,285Impact on patient access(calculated as driving miles saved per Psychiatrist and LCSW visit377,643 driving miles sa

58、ved Food SecurityNumber of Food Boxes sent to Clinics1,195*Number of Patients Screened for Food Insecurity41,229*Number of Food Boxes Distributed888*Our study of the processes utilizing a mixed-methods approach,incorporating both quantitative and qualitative data,uncovered that collaborations that w

59、ere essential part of the project typically progressed through four distinct phases:Results and Findings(continued)Results and Findings(continued)Collaborations that were essential part of the project typically progressed through four distinct phases:(i)an inception phase marked by excitement and co

60、mmitment,where participants were enthusiastic and dedicated to the collaborative effort;(ii)a brief downturn phase,often triggered by conflicts related to professional autonomy,ingrained habits,or technical difficulties,leading to challenges in collaboration;(iii)a reshaping and rejuvenation phase,w

61、here participants adjusted and refined their approach to overcome earlier challenges;and(iv)a final integration phase where the collaborative practices become integrated into routine operations,signifying the successful institutionalization of the collaborative effort.Strategies and tactics,such as

62、the establishment of model site and the cultivation of super users,were identified as key elements in facilitating the transition from the early phase to the final phase of the project.Results and Findings(continued)50MFM part of the project was completed on March 31,2023.Food insecurity part was co

63、mpleted on December 31,2023.Mental health part of the project is still ongoing.Next Steps/Follow UpThere are significant challenges facing rural women in accessing comprehensive,affordable,high-quality maternal health and mental health care.The collaborative co-management models such as the MOTHeRS Project can create a patient-centered team approach to care delivery that results in both improved patient experiences and a positive impact on maternal fetal health.Conclusions53Thank You ACKNOWLEDGEMENTS54Questions?