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Volume 8: No. 6, November 2011
COMMUNITY CASE STUDY |
Box 1. Women Enjoying Life Longer (WELL) Project Task Force | |
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Member | Consultative area |
Baltimore Medical System (federally qualified health center) | Medicine, psychiatry |
Private practice physicians, Baltimore County (n = 2) | Medicine, family practice |
Family Crisis Center of Baltimore County | Intimate-partner violence |
Johns Hopkins Bayview Hospital (local hospital):
Center for Addictions in Pregnancy |
Substance abuse |
Franklin Square Hospital (local hospital):
Family practice, case management |
Medicine, psychiatry
Health coverage |
Baltimore County Health Department:
Nutrition, mental health, vaccination, infectious disease, substance abuse, nurse practitioner, administration |
Nutrition, physical activity, vaccination, smoking cessation, sexually transmitted infections, substance abuse |
Center for Maternal and Child Health, Maryland Department of Health and Mental Hygiene | Women’s health |
Patients (n = 4), representing various age groups, races/ethnicities | Patient perspective |
Box 2. Women’s Health Services Available Through the Women Enjoying Life Longer (WELL) Project, 2004 |
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Counseling/management, all women
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General medical screening (laboratory tests) — all women as noted
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Smoking cessation, all cigarette smokers
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Screening/counseling — all women
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Vaccination — all women at risk
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a Service was already part of family planning program before WELL program. |
2) Needs assessment. Towson University conducted in-depth interviews with women residing in the pilot area (n = 20) and local health care providers (n = 10) to identify existing resources and women’s unmet health care needs. Women volunteered for the focus groups in response to flyers posted in the clinics and community sites. Providers from health organizations listed in the resource guide were contacted and volunteered to be interviewed. Nearly all of the women (n = 19) identified depression and substance abuse as key psychosocial problems, followed by domestic violence and sexual abuse. Providers echoed the paucity of domestic violence, mental health, and substance abuse services and added nutrition and dental care.
3) WELL Task Force. A local task force was established in 2001 to provide leadership and consultation to WELL. The task force included Baltimore County program offices that were to be involved with WELL and related or interested community organizations (Box 1). Four patients, recruited by the clinical staff, also provided input.
4) Selection of new services. Using resources from USPSTF, American College of Obstetricians and Gynecologists, and National Women’s Health Information Center (7-9), the WELL task force selected a core set of routine general health screenings, laboratory tests, and vaccinations for implementation (Box 2). All clinical services identified as gaps in the community needs assessment, except dental care, were added to WELL for screening, counseling, or treatment. The task force facilitated referrals for services unavailable at WELL.
5) Staff training. An essential element of WELL was staff training in all the new program areas (Box 2) that were to be integrated into the family planning program. A series of education presentations and workshops, including use of the behavioral stages of change (10), were held for the staff.
1) Full-service implementation. A core set of women’s health services (eg, adult vaccination, general screening for medical conditions, including chronic disorders, depression, substance abuse, and intimate-partner violence), counseling about nutrition and physical activity, and smoking cessation, were integrated into the family planning routines of the counselor, clinician, and exit nurse (Figure, Box 2). By 2004, WELL expanded to the Title X sites in western Baltimore County. A part-time health educator facilitated the flow of the clinic and helped the counselor with the more time-consuming activities (eg, weight management, smoking cessation, vaccinations, and other health counseling). Weight Watchers (Weight Watchers International, Inc, New York, New York) agreed to provide free registration and discounts for weekly sessions. WELL subsidized the cost to women so that no fees were incurred for 1 month of sessions. All women had their height and weight checked by a nursing assistant before seeing the clinician. During their annual examinations, all women also routinely received a screening questionnaire for intimate-partner violence that they self-administered or completed with a counselor.
Figure. Women Enjoying Life Longer (WELL) service integration during a family planning visit. Abbreviation: TSH, thyroid-stimulating hormone. [A text description of this figure is also available.]
Women were offered fasting lipid profile tests if they were at least 20 years old and fasting blood glucose tests if they were 45 years or older. Thyroid screening tests (thyroid stimulating hormone [TSH] levels) were routinely offered to women who were aged 35 years or older. All women, regardless of age, were offered these blood tests if they had any risk factors for the disorder (eg, obesity, family history, high blood pressure, or physical examination findings).
2) Evaluation. In 2004, the 11 family planning staff of eastern Baltimore County were given time during a staff meeting to complete a printed survey about the effect of WELL on the patients and staff. Also, 44 clinic users in eastern Baltimore County voluntarily completed printed surveys after their WELL clinic visit in June 2004. A 20-question quiz about women’s health was attached to the user survey. This quiz served as a follow-up to a similar quiz given to 120 family planning clients who voluntarily agreed to be surveyed during December 2001, before WELL implementation. Certain questions were changed from the 2001 test because they were not clearly worded, and others were discarded from grading if the question or answer was open to interpretation. The surveys were analyzed by Towson University and DHMH.
1) Increase in patient volume. During the third year of WELL (2004), the 3 clinical sites provided services for 1,615 women, a 28% increase in patient volume from the 1,259 women served at those same sites in 2001 before WELL. No other changes accounted for this increase. During the same period, the patient volume increased 1% for the entire Maryland Title X Program.
2) Laboratory test results. A total of 351 laboratory blood tests were conducted by WELL clinics during 2004: 180 (51%) TSH, 110 (31%) fasting lipid profile, and 61 (17%) fasting glucose tests. A large percentage of these tests were abnormal, including 84% of fasting lipid profiles, 13% of fasting blood sugars, and 8% of TSH values. Data were not recorded on how many women were offered, refused, or agreed to the tests. Also, because of the need for 12 hours of fasting before the tests, most women did not return or forgot to fast for their tests.
3) Body mass index and intimate-partner violence services. A 2006 chart review of 306 women served at 1 of the clinic sites during a 6-month period in 2004 revealed that 30% were overweight (body mass index [BMI] 25.0-29.9 kg/m2), 29% were obese (BMI ≥30.0 kg/m2), and 21% had a history of physical abuse by a current or former partner. This chart review was completed for another research project and not for WELL.
4) Evaluation: staff and patient survey of WELL. In 2004, a print survey was conducted with the 11 family planning clinic staff involved with WELL. Responders were not identifiable. All staff believed that the program had a positive effect on the community and that WELL should continue. In addition, most reported that patients appreciated the additional services (n = 10), the clinic’s ability to care for patients had improved because of WELL (n = 10), WELL did not interfere with family planning services (n = 9), and patients would be more likely to return to a clinic with WELL services (n = 8). In a discussion that followed, family planning staff voiced concerns that WELL services, however beneficial they were to the patients, were difficult to integrate without the help of an additional staff person. The WELL project coordinator, a health educator who was present at all WELL clinic sessions, was deemed essential to maintaining the flow of the clinic services.
Compared with 2001, more women in the 2004 WELL program correctly answered each of 15 questions that were identical on the 2 tests. For example, the percentage of women who knew that breast cancer was not the leading cause of death among women rose from 32% before WELL in 2001 to 80% after WELL. Women also increased their knowledge about the alcohol content of standard drinks (36% to 77%), osteoporosis prevention (19% to 68%), and daily calcium requirements (37% to 82%).
Survey questions in 2004 also included an assessment of patients (n = 44) about their satisfaction with the clinic site. When asked about their overall impression of the WELL program, most (n = 39) reported that WELL was excellent or very good, and the rest that it was good. Most women (n = 41) reported that the services they received were ones they would not have accessed if not for WELL.
One of the governor’s strategic approaches initiated in 2008 to reduce infant mortality is focused on improving general health before pregnancy. Public health family planning clinics recently have begun to offer more comprehensive women’s health services, similar to the WELL concept, in the 3 counties with the highest infant mortality rate.
Since 1970, the Title X Family Planning Program has played a critical role in providing contraceptive and related preventive services to predominantly low-income and uninsured people (11). The WELL project’s integration of comprehensive preventive women’s health services into the family planning program allowed women who had difficulty accessing care a means of improving their health while taking care of their reproductive health needs. We determined that risk factors (eg, obesity, dyslipidemia, domestic violence) were already prevalent among young women at the WELL sites. Most women surveyed believed that WELL provided them with health care services that they otherwise would not have accessed. Their general knowledge of women’s health also increased. Equally important, 8 of the 11 family planning staff surveyed believed that WELL did not interfere with delivery of family planning services. Furthermore, patient volume increased dramatically during the project period, perhaps reflecting the need for women’s health services among this population as identified in the initial needs assessment. Women’s health services also have the potential to expand reproductive health choices. For example, according to 1 WELL clinician’s experience, smoking cessation allowed women aged 35 years or older to remain on oral contraceptives, and weight management improved continuation rates for women who experienced substantial weight gain with progestin-injectable contraceptives. Moreover, helping women leave a physically violent relationship liberated them from their partner’s coercive demands on birth control use. Data from WELL did not capture the prevalence of these treatment results other than anecdotally.
The WELL project served as a bridge between family planning, prenatal, preconception, and interconception care, an ideal merger of the Title V, a federal block grant program to states for the improvement of maternal and child health, and Title X programs. Although optimizing perinatal health seems antithetical to a woman whose immediate objective is pregnancy prevention, the family planning visit may be the only opportunity that a woman has to receive advice about and treatment of conditions before pregnancy. The high unintended pregnancy rate in the United States of approximately 50% (12) indicates that integration of primary care, preconception health, and reproductive health at any time young women access health visits is beneficial. For women with difficult access to care, Title X programs and others that are publicly funded (eg, community or federally qualified health centers) can help integrate women’s general and reproductive health (13,14). Adequate staffing and funding for these sites, perhaps through Medicaid expansion, may be necessary before any site can accommodate additional services.
In retrospect, we should have spent more time setting up a data system to capture the number of women who were eligible and participated in each of the WELL activities, along with their diagnoses, treatments, referrals, and follow-up. These data would have been useful for providing a cost-benefit analysis of the program, estimating the prevalence of acute and chronic disorders, and evaluating our ability to assess, treat, and refer women for non–reproductive disorder services in a family planning program.
In our experience with WELL, staff acceptance of the program was the most important ingredient for the project’s success. During WELL’s implementation, every staff member and administrative leader was enthusiastic about the women’s health services and was an active participant in the decision-making process. As the natural turnover of staff occurred, the enthusiasm lessened. After the grant cycle was over, the budget for WELL was limited. Donated supplies (eg, nicotine patches, varenicline [a prescription drug approved for smoking cessation in 2006]) and funding for certain vaccinations have kept these services intact and strong. Family planning staff still offer nutrition education and health counseling; however, loss of the WELL health educator has made devoting the time desired for certain interventions challenging. Availability of other WELL services (eg, domestic violence or depression screening, treatment, and referral) remains entirely dependent on the individual health provider’s interest and expertise. Routine population-based blood screening tests proved too costly to maintain.
WELL earned staff acceptance by training staff and encouraging their active participation in the decision-making process. Equally important, leadership from the multidisciplinary community task force facilitated for the staff the coordination of all new clinical services.
The integration of women’s health with reproductive health services can provide young women a convenient way to optimize their general health, plan their pregnancies, and receive preconception and interconception services.
The WELL Project gratefully acknowledges the financial and programmatic support of the Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services. WELL also acknowledges the programmatic and clinical support of the Baltimore County Department of Health, Towson University, and the Title X program.
Corresponding Author: Diana Cheng, MD, Maryland Department of Health and Mental Hygiene, 201 W Preston St, Rm 313, Baltimore, MD 21201. Telephone: 410-767-6719. E-mail: chengd@dhmh.state.md.us.
Author Affiliation: Priti Patel, Center for Maternal and Child Health, Maryland Department of Health and Mental Hygiene, Baltimore, Maryland, and Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia.
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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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