The Maternal Infant Dyad-Implementation Project: Stories from the Field
By Meg Bowen, Kit Meyer, & the MInD-I Team
Around fifteen percent of women in pregnancy and the year postpartum suffer from common mental disorders such as depression (perinatal depression) or anxiety, yet evidence-based strategies to identify and treat these conditions are rarely used in their medical care. Many health care providers are unaware that these serious disorders – which impact both mothers and their children – are equally common in pregnancy as postpartum, or that suicide, usually occurring among those with depression, is a leading cause of maternal mortality. The Maternal Infant Dyad – Implementation (MInD-I) project brings the collaborative care model (a team-based, patient centered strategy shown to improve health outcomes for diverse patients) to participating members of the OCHIN community health center (CHC) network.
In honor of National Mental Health Awareness Month, we are proud to share the experiences of two community health centers who are participating in the MInD-I initiative.
Meg Bowen: Winding Waters Clinic
Rose was struggling to get a handle on the mounting pressures in her life; balancing a new marriage, a full time job, raising a precocious eight year old and now a pregnancy. She faced each day with dread knowing that the heart palpitations, the flood of emotions and the overwhelming exhaustion were taking a toll. She moved through her days with fear knowing that one more change would be more than she could handle, and she feared she would break into a thousand pieces. She took great pride in the fact that she could handle anything; she was rodeo-tough, a product of the rough and tumble landscape of eastern Oregon. Where could she turn to for support? Who could possibly understand the stressors she faced? During her first pre-natal visit, she completed a PHQ-9 and GAD-7 questionnaire/screener, and received a warm hand-off from her PCP to the Collaborative Care Manager. He spoke softly with Rose as the tears began to flow down her face. Someone was listening, this was safe; she could let her guard down and just exhale. After speaking with Rose, the Collaborative Care Manager enrolled her in the MiND-I Collaborative Care Model (CoCM) for perinatal care being implemented at the clinic.
In the behaviorist model of integrated behavioral health (IBH), behavioral health staff are embedded within the clinic and are available for warm handoffs and referral for brief interventions. They work in concert with the PCP to meet the needs of the patient. This model of care is very effective, and is one that many clinics strive to implement successfully.
In contrast, the Collaborative Care Model (CoCM) is an evidence-based and patient centered model developed by the AIMS Center at the University of Washington. Primary Care Providers, Care Managers and consulting Psychiatrists collaborate using shared care plans and other tools. It is population health based, in which a defined group of patients is tracked in a registry, and the CoCM team prioritizes outreach and shared care decisions. Progress is measured regularly, and treatments are actively adjusted until clinical goals are achieved.
After screening for depression and anxiety, the PCP performs a warm hand-off to the Care Manager, who provides brief therapeutic and patient activation support. The Collaborative Care Manager leverages the Epic EHR registry to track patient outreach and clinical outcomes, and conduct weekly consultation with the Psychiatric Consultant in order to identify patients who need treatment adjustment or intensification. The Care Manager can implement an adjustment to treatment for patients not improving as expected, including the treat-to-target goal of a 50% reduction in PHQ-9 scores. Once treatment goals are achieved, a patient like Rose is transitioned from intensive management to a maintenance mode of care.
The relationship that the Care Manager builds with the patient is critically important to maintaining the connections to care, in the same way that the routine meetings with Psychiatric Consultant are integral to managing symptom improvement. The consulting Psychiatrist, the Care Manager and the PCP work together to meet the needs of the patient, and the shared care plans and registry assure that all are in communication about the status of the patient.
In September of 2018, Rose delivered a beautiful baby girl. She continues to remain engaged in the Collaborative Care Model, and is feeling much better and enjoying raising the next generation of rough and tumble eastern Oregon women.
Kit Meyer: Open Door Community Health Centers
Have you ever had a nervous feeling in the pit of your stomach about that patient that you knew was struggling with mental health issues?
The caring members of our staff at Open Door Community Health Clinic’s specialty clinic, NorthCountry Prenatal, has had their share of moms and babies that left after their six week appointment, leaving us hoping they would get to their referrals and recommended follow up.
We made the referrals, set up appointments, and had an imbedded therapist support a transition of care. In addition, we had been screening women in pregnancy and postpartum for depression and referring them to therapists in the clinic and in the community, but this wasn’t enough. After a few tragedies impacting mother and newborns in our community, we set out to do better. This was the moment the AIMS Center at The University of Washington and OCHIN came to us with the MIND-I project. We were happy to try a new approach to support this group of high risk patients.
In March of 2017, we set off on a journey to address mental health in more visits, consistently screen prenatal and postpartum patients, and work with the resources in our clinic system and in the community to provide a support team. The University of Washington and OCHIN provided a guide for implementing Collaborative Care, in which our patient is the focus, and we use psychiatry and behavioral health as resources for the medical care provider. Over the past two years we have used this strategy with over 200 prenatal and postpartum patients. Currently we hold weekly reviews with a Care Manager and psychiatrist, reviewing patients with any mental health concern or psychiatric medication management needs. We also host monthly meetings of key clinic staff, including the front desk staff, medical assistants, and nurses, who serve as the eyes and ears of the providers; input from the combination of all of these teams led to complete care and follow up.
As we have moved forward, we have added an additional therapist to our in-clinic staff, and provided our delivering hospital with more detailed mental health information for patients in anticipation of delivery. We hope to continue transitioning to this method of care in additional clinics, and further develop our entire clinic staff’s capacity to identify and address mental health factors in the prenatal period.