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One Appointment, Multiple Healthier Outcomes: Screening Moms at Well-Baby Visits

Shannon, a 21-year-old woman from Lancaster, brings her newborn to the doctor for a well visit. During the visit, the doctor asks if she smokes. About 75 percent of women who stop smoking while pregnant start again after delivery, and Shannon is no exception, but tells the doctor she is interested in quitting. The doctor tells her about a free program to help her stop smoking and offers to prescribe the drug bupropion to curb her nicotine cravings. At her baby’s next exam, the doctor will check on Shannon’s progress.

Jess is 24 years old and lives in Philadelphia with her boyfriend. She has a 3-month-old baby and a 15-month old toddler. At her baby’s well visit, the doctor asks if she would like to become pregnant over the next year. She answers no. Roughly 25 percent of mothers who don’t wish to conceive in the foreseeable future also don’t use contraception in the first 12 to 15 months post-delivery. Jess is not currently using birth control, but doesn’t want to get pregnant for another two to three years. The doctor talks to her about long acting reversible contraception (LARC) and schedules an appointment to implant Nexplanon in her arm, which will provide safe, reliable birth control.

A Simple, Yet Powerful, Idea

The above scenarios, while not real cases, represent what is taking place in a growing number of family medicine offices every day, thanks to a program with strong ties to Penn Medicine’s Lancaster General Health (LG Health). IMPLICIT, a multi-site, practice-based quality improvement network, has established a model for interconception care (ICC) — the period of time between the birth of one baby and the conception of the next — to improve the outcomes of future pregnancies. It benefits mothers and babies as well.

Launched in 2004 by a group of physicians including Stephen D. Ratcliffe, MD, director of the Family Medicine Residency Program at LG Health, IMPLICIT (Interventions to Minimize Pre-term Labor and Low Birth Weight Using Continuous Quality Techniques) operates under the not-for-profit Family Medicine Education Consortium (FMEC). LG Health’s Research Institute is responsible for data management and analytics for IMPLICIT.

Planning for the IMPLICIT ICC model began in 2006 when the March of Dimes, a major funder for the FMEC, connected physicians from IMPLICIT with staff from the Centers for Disease Control and Prevention (CDC), to address the lack of preconception care for women in the United States.

“We decided to adopt some of the interventions my former colleagues and I performed in Salt Lake City in the 1990s,” Ratcliffe said, explaining that each time they saw a baby up through age two, the team would also look at the mother’s chart. “We found that many women would see their OB/GYN for one postpartum visit, but wouldn’t return until they conceived again. However, moms did attend nearly all of their babies’ well-child visits, providing an opportune time for screening.”

Mario P. DeMarco, MD, MPH, an assistant professor of Clinical Family Medicine, has been active with the IMPLICIT network since 2012 and is a champion for interconception care.

“Like many other women’s health providers, I find that caring for women between pregnancies can be a challenge when visits are limited,” he said. “The IMPLICIT ICC model addresses this by paralleling the medical home as a model for evidence based care. It enables us to provide assistance to a population of reproductive-age women, regardless of whether they visit their usual source of care.”

Focus on Four

Under the IMPLICIT ICC model, physicians or nurses speak with mothers during each well-baby visit from birth through 24 months, focusing on four key factors linked with premature or low birth weight babies: smoking, depression, lack of contraception to prevent pregnancies that are spaced too closely, and the importance of prenatal vitamins with folic acid.

Providers ask simple questions to screen for risks, educate mothers about healthy behaviors, assess any positive screens and offer direct intervention or referrals for care, and collect data for quality improvement research.

The screening questions for smoking and depression are quick, yet effective.
Are you smoking?
Do you want help quitting?
In the last few weeks, have you often felt down and depressed?
Have you often felt that you did not want to be around other people?

For patients who screen positive for depression, there is a process to assess for self-harm at that first visit and to provide follow-up care within a week for women with probable moderate to major depression.

The providers also ask women if they would like to become pregnant, educate them about the importance of allowing at least 12 to 18 months between deliveries, and offer access to birth control if needed. Women are also advised to take a daily multivitamin with adequate levels of folic acid, which is linked to healthier future pregnancy outcomes. This screening can be efficiently integrated into the well-child care visits.

A Feasible Model of Care

The IMPLICIT network includes more than 20 sites, with locations as far as Mississippi, North Carolina, and Massachusetts. All but two are family medicine practices. The collected data provides valuable information to drive quality improvement and spans a variety of settings, from urban to suburban to rural, across all socioeconomic demographics.

“Before we implemented this study, we assessed about a dozen sites and learned that roughly 25 percent of our family doctors were already asking questions like these during well-baby visits. Under this program, we are now screening mothers for interconception care at 80 percent of visits,” Ratcliffe said.

Next month, the American Board of Family Medicine will publish a paper about the implications and scalability of the IMPLICIT ICC model. Ratcliffe hopes the ABFM’s support will aid in getting physicians across the country to adopt the care model.

“We find that in most family medicine practices, such as ours in Lancaster, 95 percent of the time when we treat a baby, the mother is also a patient in our office, so combining well checks to this extent is not difficult to do,” he said.

DeMarco would like to see the ICC model expand to more pediatric practices. For at least a decade, the American Academy of Pediatrics has recommended that general pediatricians screen for maternal depression. The IMPLICIT team will be exploring how to make all four screenings more feasible in the pediatric setting.  

“We are looking for opportunities to train pediatric providers to implement this type of care more broadly in order to impact more and more families,” DeMarco said. “I am working with folks from Children’s Hospital of Philadelphia and hope that someday interconception care at well-child visits will become the standard of care for all families in West Philadelphia.”.

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