ONE KEY QUESTION®
An initiative of the Oregon Foundation for Reproductive Health ONE KEY QUESTION® IN PRIMARY CARE
A simple screening question to facilitate a conversation with your patient regarding her pregnancy intention
Designed to help you ID the preventive reproductive health care needs of your patient’s
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FACTS Most American families want two children. The average woman is fertile for 39 years and spends 3 decades trying to avoid an unintended pregnancy. She spends about 5 years pregnant, postpartum or trying to become pregnant.
Currently, about half (51%) of the 6.6 million pregnancies in the United States each year are unintended
By age 45, more than half of all American women will have experienced an unintended pregnancy
Guttmacher Institute- Unintended Pregnancy in the United States- Jan 2015
3 MORE FACTS
In Oregon, 2011:
43.5% of pregnancies were unintended 55.7% of all deliveries were paid for by Medicaid 48.7% of women did not take a prenatal or multivitamin prior to conceiving
PRAMS 2011: Oregon Department of Human Services, Public Health Division, Pregnancy Risk Assessment Monitoring System
4 UNINTENDED PREGNANCY IS ASSOCIATED WITH…
Health problems for both mother and infant including:
Preterm birth, low birth weight, increased infant mortality
Delayed prenatal care
Increased depression, anxiety & physical abuse for mother
5 IN REALITY…
Most unintended pregnancies are unwanted or mistimed, and most could be prevented with better access to contraception
Some unintended pregnancies are wanted, and could be better prepared for with access to preconception care
6 CONTRACEPTION WORKS
35% of women at risk of becoming pregnancy have nonuse or inconsistent use of birth control
Guttmacher Institute: Unintended Pregnancy in the United States. December 2013 7 OUR SOLUTION
Ask all women of reproductive-age One Key Question® as a routine part of primary care:
8 PREGNANCY INTENTION SCREENING
One Key Question® is a screening tool to help identify women in need of preventive reproductive health care
framed as “Would you like..” to hear your patient’s own goals for her health
followed by evidenced-based care can have a big impact on your patient population health
9 PREVENTIVE REPRODUCTIVE HEALTH
Contraception and preconception care offered in a proactive and routine way!
10 THE ONE KEY QUESTION® ALGORITHM
11 IF YOUR PATIENT ANSWERS ‘YES’ Preconception Care
Screen for conditions that can affect pregnancy Review medications Recommend Folic Acid Talk about the benefits of birth spacing
12 ADDITIONAL PRECONCEPTION ADVICE
Advice to reduce/eliminate alcohol, tobacco, street drugs Review prescribed and OTC medications, supplements, herbs Screen for STIs, diabetes, hypertension Check if immunizations are up to date Recommend healthy diet, daily exercise, sleep, stress reduction Advise a dental cleaning/check up Screen for risk of intimate partner violence Establish relationship with primary care provider
13 IF YOUR PATIENT ANSWERS ‘NO’
Contraceptive Services
Ask if she is currently using a birth control method
Check on her satisfaction with current method
Offer more options, including long-acting reversible contraceptives (IUD, Implant)
Include information on emergency contraception
14 CONTRACEPTION BASICS Many women use short-term or less reliable contraception because it’s what they are used to
The best method for women usually changes with time or with pregnancy/birth
There are great long-acting reversible contraception (LARC) methods that would be ideal for many women 15 LARC’S
Protect against pregnancy for multiple years Reduction of user-error: no need for woman to do anything for them to work More effective than other methods with fewer side effects Women can have them removed anytime they want with rapid return to fertility
16 LARC’S
Intrauterine Devices (IUDs) Paragard = 12 years (no hormones) Mirena = 5 years Skyla= 3 years Implantables Implanon = 3 years Nexplanon = 3 years
17 ‘UNSURE’ OR ‘OK EITHER WAY’
Follow up
Offer a combination of contraception & preconception care
Discuss relevant issues
18 ‘UNSURE’ OR ‘OK EITHER WAY’ Many women are unsure or ambivalent, especially if they’ve never been asked! You can start a conversation:
Is now the right time? Do you have the resources you need for another child (money, time, child care, space)? How would having another child impact family work plans, education plans, financial status?
19 FOLLOW UP QUESTIONS
Use the 1-10 scale to gauge ambivalence or ask “How important is it to you to prevent pregnancy?”
•“Why would you say you aren’t a lower number?” •“Why do you think your number might not be higher?” •“I hear you have mixed feelings, but it’s something you’re thinking about. How can I help?”
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FOLLOW UP RESPONSES:
“I would recommend you chose a contraceptive method to protect against pregnancy until you are sure.” “I want you to know in a year’s time- 85 out of 100 women who have unprotected sex will become pregnant.
“What would you like to do?” “How can I help you reach your goal?” 21
OVERCOMING BARRIERS
Risky Assumptions by Providers: “This person should not become pregnant – I won’t offer preconception care” “This patient is getting reproductive health care somewhere else” “This patient knows how to use their birth control correctly”
UNDERSTANDING YOUR PATIENTS GOALS WILL HELP YOU Identify THE PREVENTIVE REPRODUCTIVE SERVICES THEY NEED.
22 OVERCOMING BARRIERS
Time intensive to ask: “There is not enough time in a PC visit to address RH needs”
Our pilot showed: OKQ is feasible in a PC visit and acceptable to patients to ask- even at ‘non reproductive health visit. Only about 30% of women asked will need f/u care.
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ONE KEY QUESTION® OUTCOMES
@ Community Health Clinics: 30% of women needed follow-up with contraception or preconception care 70% did not require any follow-up services
@ Public Health Clinics: 60% of women were happy with their current method of contraception 23% received new contraception services 12% were given preconception care and advised to start folic acid
WHY PRIMARY CARE? Screening for pregnancy intention and providing follow-up services is essential for primary care to manage chronic conditions before conception
Pregnancy Intention can change for women throughout the year – so ask often, not only at Well-Woman visits
The ACA now requires insurance to cover preventive care for women including all FDA approved birth control, some preconception care & folic acid, prenatal care, and more! 25
OTHER SCREENINGS IN PRIMARY CARE
Established Indicators of High Quality Care include Depression screening (PSQ-2 and 9) Alcohol misuse (SBIRT) Cervical cancer screenings (Paps) Breast cancer screenings (exams, mammography) Blood pressure Diabetes screening (blood glucose and HgbA1c)
26 LIFETIME RISK
27 ACHIEVE THE “TRIPLE AIM”
Improve health outcomes Improve the experience of care (quality and satisfaction) Reduce per capita costs
28 PCPCH METRIC Patient Centered Primary Care Home (PCPCH) standard for age and gender appropriate services that meet the HRSA-recommended preventive services for women:
Contraceptive methods and counseling
Folic Acid use
“Screening methods described by the One Key Question® Initiative are adequate to meet these services”
29 CCO METRIC
“Effective contraception among women at risk of unintended pregnancy”
Incentivized metric for Coordinated Care Organizations for 2015!
Oregon is 1st in the nation to adopt a preventive reproductive health metric!
30 ONE KEY QUESTION® IS DESIGNED TO…
Start a conversation about preventive reproductive health in primary care Prevent pregnancies that are unwanted or mistimed Increase the proportion of pregnancies that are better prepared for.
31 OFRH SUPPORT Implementation Manual Clinic and Staff inventory Various algorithms for screening
Custom Consultations Clinic Flow, Data Collection Additional trainings for providers and team
OKQ patient brochures and posters
32 CONTACT US
Oregon Foundation for Reproductive Health Michele Stranger Hunter- Executive Director Sharon Meieran, MD, JD- Co Medical Director Julia Epstein, NP- Co- Medical Director Hannah Rosenau- Senior Policy & Access Coordinator [email protected]
Follow us on Facebook and Twitter: Oregon RH www.onekeyquestion.org
33 PREGNANCY INTENTION SCREENING USING: ONE KEY QUESTION
Jennifer Johnstun, RN – PrimaryHealth CCO Maggie Sullivan, MPH – Health Care Coalition of So. Oregon Belle Shepherd, MPH - OHA FORMATION OF THE CONSORTIUM
1990s - Jackson County Perinatal Task Force formed by Jackson County Medical Director
2008 - Josephine County Perinatal Task Force formed by Josephine County Public Health Manager
2012 – Southern Oregon Perinatal Task Force forms, merging efforts of both counties, and relationships with Managed Care Organizations continue through formation of CCOs ORGANIZATIONS IN THE CONSORTIUM
Public Health – Jackson and Josephine CCOs – Allcare, Jackson Care Connect, PrimaryHealth FQHCs – Siskiyou Community Health Center, La Clinica, Rogue Community Health Other partners: Women’s Health Center, Siskiyou Pediatrics, Asante Health Systems, DCOs and Dentists, Family Nurturing Center, Drug and Alcohol clinics, Head Start and Early Head Start MISSION STATEMENT
To improve the health and well-being of pregnant women, infants, and young children by empowering women and families to make healthier choices for themselves and their babies, before, during and after pregnancy. (Adopted January 2013) FUNDING RECEIVED FROM OHA, COMMUNITY PREVENTION GRANT
Fiscal Agent & Project Direction-Funded 10/2013: Jackson County Public Health
Project Management: Health Care Coalition of Southern Oregon A 501(c)-3 non-profit organization made up of public health agencies & community health centers in Jackson, Josephine & Douglas Counties HEALTH OUTCOME MEASURES TO BE TRACKED
The steering committee for the Community Prevention Grant determined the following outcome measures: Early Entry into Pre-natal Care Teen Pregnancy Rate Teen Birth Rate Unintended Pregnancy Rate Contraceptive Use Rate
ONE KEY QUESTION (OKQ) IMPLEMENTATION
Steering committee formed to: Identify champion agencies to start screening Plan for training and education efforts Review materials to be used Address implementation problems
ROUTINELY SCREEN WOMEN FOR THEIR PREGNANCY INTENTIONS (ALIGNED WITH OHA STRATEGY #1)
Paper form used by WIC, MIECHV Programs:
WORK UNDERWAY TO EMBED OKQ IN OCHIN/EPIC & OTHER EMR SYSTEMS
Medford FQHC, La Clinica, initiated request to build OKQ algorithm into OCHIN/EPIC. Work teams provided input on work flow outline (Outside-In, Multnomah Co PH, Wallace Medical Concern, OPCA, La Clinica). CareOregon donated staff time to assist with build. Build in-process Other clinics looking at how to embed in their EMRs Efforts to integrate OKQ with EMRs make it easier for providers to implement an OKQ workflow OHA STRATEGY #2: REMOVE BARRIERS TO CONTRACEPTION
Education for providers and members regarding OHP’s coverage of all methods of birth control (and how/where to obtain this from CCOs). Request to local CCOs to provide at least 3- month supply of Birth Control Pills Client education on effectiveness of methods
STRATEGY #3: IMPROVE AVAILABILITY AND INCREASE REFERRALS FOR LARCS – LONG-ACTING REVERSIBLE CONTRACEPTION
Development of Local Family Planning Referral Grid, with info on where to get contraceptives
Education Materials
Contraceptive Update Training for providers and clinics
Family Planning Referral List for Jackson and Josephine Counties Clinic Title X CCARE OHP Private Ins Sliding Scale Walk-in Methods offered (Title 10) Welcome Jackson County Public Health 541-774-8209 IUD 1005 E. Main St Pills Medford, OR Ring **Moving in December 2014** Shot Patch 140 S. Holly St. ● ● ● ● ● ● Condoms Medford, OR 97501 Emergency Contraception Community Health Center Ashland Clinic White City Clinic IUD 541-482-9741 541-826-5853 Pills 99 Central Ave 8385 Division Rd Implants Ashland, OR 97520 White City, OR 97503 Ring ● ● ● ● Shot Medford Clinic Butte Falls Clinic Patch 541-773-3863 541-842-7799 Condoms 19 Myrtle St 722 Laurel Ave Emergency Contraception Medford, OR 97504 Buttle Falls, OR 97522 La Clinica 541-618-1300 IUD Phoenix Health Center Women's Health Center Pills 3617 S. Pacific Hwy 910 S. Central Ave Implants Medford, OR 97501 Medford, OR 97501 Ring Shot West Main Health Center Central Point Health Center ● ● ● ● Patch 1307 W. Main St. 4940 Hamrick Rd. Condoms Medford, OR 97501 Central Point, OR 97502 Emergency Contraception
Planned Parenthood 541-344-9411 IUD Ashland Medford Pills 1532 Siskiyou Blvd. 125 S. Central Ave Implants Ashland, OR 97520 Medford, OR 97501 Ring ● ● ● ● ● ● Shot Grants Pass Patch 160 Franklin Blvd Condoms Grants Pass, OR 97526 Emergency Contraception
Josephine County Public Health 541-474-5325 Ring 715 NW Dimmick St Pills Grants Pass, OR Shot ● ● ● ● ● ● Patch Condoms Emergency Contraception Siskiyou Community Health Center IUD 541-472-4777 Pills 1701 NW Hawthorne Ave 25647 Redwood Hwy Implants Grants Pass, OR 97526 Cave Junction, OR 97523 Ring ● ● ● ● ● Shot Patch Condoms Emergency Contraception Women's Health Center of Southern Oregon IUD 541-479-8363 Pills 1075 SW Grandview Ave Suite 200 Implants Grants Pass, OR 97527 Ring ● ● ● ● Shot Patch Condoms Emergency Contraception If you have health insurance, they MUST cover ALL birth control methods at NO COST to you. If you are uninsured, you may still qualify for free or low cost birth control under Title X (10) or Ccare, please see guidelines below. Title X (Title 10) Title X (called "Title Ten") is a Federal Grant Program providing confidential family planning and reproductive health services to low-income, uninsured, and undocumented individuals at reduced or no cost. Title X Clinics cannot refuse services based on ability to pay, and offer a sliding scale fee based on income. Individuals at or below the federal poverty level pay nothing. Oregon Contraceptive Care (CCARE): CCARE offers free contraceptives, contraceptive counseling and annual exams to women and men who meet financial guidelines and eligibility requirements listed below: 1. Live in Oregon 1 $561 $2,432 2. Have income up to: 2 $756 $3,278 3. Present photo ID 3 $951 $4,123 4. Have a Social Security number (SSN) For each additional person add: $195 $846
Primary Care - You may have a primary care provider that offers Family Planning Services For private insurance, call you insurance company, and ask to speak with a representative. For Oregon Health Plan , contact your Care Coordinated Organization (CCO). AllCare CCO - 541-471-4106 Jackson Care Connect CCO - 1-855-722-8208 Primary Health of Josephine County CCO - 54Ve1-rs47ion1-42 3 08, update 8/2014 STRATEGY #4: CREATE QUALITY IMPROVEMENT PROCESSES FOR PRECONCEPTION & CONTRACEPTIVE CARE
Initial OKQ Data from WIC was compiled. WIC staff receives data back for QI regularly. What percent of women not currently on BC were referred for contraception? What percent of women are taking daily multi-vitamins? What percent of women receive info on preconception health & primary care? WIC DATA (JACKSON COUNTY NOVEMBER 2014) WIC DATA “YES” WIC DATA “NO” WIC DATA “NO, AND USING BIRTH CONTROL” STRATEGY #5: BUILD PROVIDER AWARENESS AND CAPACITY FOR EFFECTIVE CONTRACEPTIVE USE
Reproductive Health Update Training - November 13, 2014 – Presented by CARDEA & Dr Deborah Oyer Plenary Contraceptive Update Attended by 80 Clinical Case Management for Contraceptive Care – Attended by 30 providers Contraceptive Counseling Session- attended by 30 health workers IUD Insertion Training – attended by 30 providers Nexplanon Insertion Training – attended by 25 providers
STRATEGY #6: ENHANCE PARTNERSHIPS WITH LOCAL FAMILY PLANNING CLINICS
Outreach to family Planning clinics – distribution of patient education materials and multi-vitamins Roll-out of One Key Question at County Health Dept Family Planning Clinics
Family Planning Referral Grid CONCEPTS FOR CCOS TO CONSIDER
How do we build motivation to address this? (One Key Question is One More Thing) How does this fit into each PCPCH’s vision for how they wish to provide care? How can CCO and clinic priorities align(Ex: Shared Decision Making?) What did we learn from SBIRT implementation that can help us with rolling out this initiative? How can we work together as a community of providers to accomplish this?