Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation (Assistance), Concurrent Infant/Mother Checkups

Intervention Description: The Mother-Infant dyad postpartum primary care program was part of Ohio Gestational Diabetes Postpartum Care Quality Improvement Collaborative, a multi-year initiative sponsored by the Ohio Departments of Health and Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The Dyad program evaluation was conducted in the context of a quality improvement (QI) initiative aimed at increasing postpartum type 2 gestational diabetes (T2DM) screenings during the 4–12 week postpartum period and also increasing postpartum visit attendance with a prenatal provider. Women were eligible for the Dyad program if they lived in central Ohio and had a diagnosis of gestational diabetes mellitus (GDM) during the most recent pregnancy or condition suggesting previous undiagnosed GDM. Following delivery, Dyad program appointments occurred concurrent with the infant’s well-check visits and allowed mothers to access comprehensive postpartum care services including but not limited to postnatal screening for T2DM, health and wellness education, breastfeeding support, and referrals to specialty services if indicated. An on-site patient navigator contacted mothers by phone in advance of the visit to address barriers to care including transportation and childcare. Reminders were also sent via phone and electronic health record (EHR) patient portal to con- firm attendance. The Dyad program facilitated postpartum obstetrics to primary care hand off to improve longitudinal care engagement for disease management and prevention.

Intervention Results: Women who participated in the Dyad program were more likely to complete a postpartum visit and receive type 2 diabetes mellitus (T2DM) screenings than women who did not participate. In addition, fewer women who participated in the program experienced new T2DM diagnoses (17%) than those in the comparison group (29%), yet a greater proportion of Dyad program participants experienced new predia- betes diagnoses (12%, p<.001) than those in the com- parison group (6%, p<.001).

Conclusion: The Mother-Infant Dyad postpartum primary care program improved type 2 diabetes mellitus screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program partici- pants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.

Study Design: Analysis of patient surveys, claims data, and administrative records

Setting: Midwestern academic medical center internal medicine and pediatrics primary care clinic

Population of Focus: Postpartum patients with a previous diagnosis of gestational diabetes mellitus

Sample Size: 75 mother-infant dyads

Age Range: Mean age 30.75

Intervention Components (click on component to see a list of all articles that use that intervention): Patient Navigation, Concurrent Infant/Mother Checkups

Intervention Description: Following randomization, participants in the mommy-baby visit arm were scheduled for a co-located, co-timed postpartum/well-child visit at 4 weeks after delivery designed through a partnership between obstetrics and pediatrics. The pediatricians performed the infant's checkup either in the same patient room as the mother's obstetric visit or in the adjacent pediatric practice immediately before the postpartum visit. Women randomized to the control group received usual postpartum care, separate maternal and child visits. Their usual care was “enhanced” in that study staff scheduled participants' postpartum visits before hospital discharge.

Intervention Results: One hundred sixteen women, of whom 76.7% (n = 89) were Latina immigrants, were enrolled postdelivery and randomized to a mommy-baby visit (n = 58, 49.5%) or to enhanced usual care (n = 58, 50.4%). Almost all study participants attended their postpartum visit (n = 109, 94.0%). There was no significant difference in postpartum visit attendance rate by randomization assignment (91.4% of mommy-baby vs. 96.6% of enhanced usual care participants). Study participants, mommy-baby intervention and enhanced usual care arms combined, were significantly more likely to attend the postpartum visit than historical controls (94.0% vs. 69.7%, respectively, p < 0.001).

Conclusion: In a randomized controlled trial, we showed postpartum visit attendance rates were high for participants in both the mommy-baby and enhanced usual care arms. Postpartum visit scheduling assistance was provided to all participants and may have increased postpartum visit attendance and thereby attenuated the effect of the intervention. It is encouraging that a low-cost, low-tech, low-touch intervention, that is, postpartum appointment scheduling before hospital discharge, could increase postpartum visit attendance.

Study Design: Randomized control trial

Setting: Large academic hospital in Baltmore

Sample Size: 116 low-income postpartum women with limited English-langauge proficiency

Age Range: >18

Intervention Components (click on component to see a list of all articles that use that intervention): Patient-Centered Medical Home, Concurrent Infant/Mother Checkups

Intervention Description: Jointly scheduling PP visits and the 2-month well infant visits.

Intervention Results: Of the 74 patients enrolled, 41.9% were Hispanic and 17.6% were Black, mean age was 31.6 years, and 58.1% delivered vaginally. Attendance at the 6-week PP visit was 68.9%, and attendance at the infant visit was 55.1%. PP glucose testing was ordered for 76.5% of attendees at the PP visit, and of those ordered, 43.6% of attendees completed testing. All patients had joint visits requested, though only 70.3% of visits were scheduled jointly. Among those who were jointly scheduled, 71.2% of women attended, 57.7% of infants attended, and 7.7% of pairs attended on the same day. The PP visit attendance rate was not significantly different than the prior attendance rate (p = 0.84)

Conclusion: This study was unable to improve PP visit attendance among women with GDM by jointly scheduling the 6-week PP visit and the 2-month well-infant visit. Future research could be directed toward a shared space where both women and children can be seen to attempt to increase PP visit attendance and monitoring for women with GDM.

Study Design: Cohort study

Setting: New York City-based publicly insured hospital clinic

Population of Focus: Patients with gestational diabetes (GDM)

Sample Size: 74

Age Range: Reproductive age

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, Concurrent Infant/Mother Checkups

Intervention Description: The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network, a family medicine maternal child health learning collaborative of the Family Medicine Education Consortium, created a model of intercconception care (ICC) that addresses barriers to care by screening women during well-child visits (WCVs). The IMPLICIT Network develops, implements, evaluates, and optimizes new and existing models of care focused on improving birth outcomes and the health of women, infants, and families. In this model, clinicians assessed pregnancy status, intent, and current method of contraception and offered counseling and interventions. Mothers were also screened for depression. Clinicians screened mothers at well-child visits from 2 to 24 months. Mothers received screening and advice regardless of whether or not she received primary care from the same provider or practice. A variety of services were available to the participating clinicians on site, including case management, social workers, community health workers, substance abuse counselors, and office-based pharmacists. Each family medicine practice offered patients access to mental health counseling, with 6 of the 11 sites reporting availability of colocated, integrated behavioral health models.

Intervention Results: Mothers accompanied their babies to 92.7% of WCVs. At more than half of WCVs (69.1%), mothers were screened for presence of ICC behavioral risks, although significant practice variation existed. Risk factors were identified at significant rates (tobacco use, 16.2%; depression risk, 8.1%; lack of contraception use, 28.2%; lack of multivitamin use, 45.4%). Women screened positive for 1 or more ICC risk factor at 64.6% of WCVs. Rates of documented interventions for women who screened positive were also substantial (tobacco use, 80.0%; depression risk, 92.8%; lack of contraception use, 76.0%; lack of multivitamin use, 58.2%).

Conclusion: Based on the findings of this study and the clinical experiences of participating sites with the IMPLICIT ICC model, several key recommendations can be offered to clinical practices seeking to implement this model for interconception care. Practices should develop standardized screening protocols, tools for point-of-care intervention for women who screen positive in any of the four key behavior risk areas, such as patient education materials and clinical management algorithms, and linkages with local community agencies so they may refer women needing additional resources not offered on site, such as depression care or contraception access. Practices should also strive to use quality improvement techniques to improve both screening and intervention rates. Practices that serve populations with limited resources such as uninsured, undocumented, or immigrant communities would gain particular benefit from implementing IMPLICIT ICC as a way to reach women not seeking care. Based on their particular population's needs, clinical practices might consider expanding the IMPLICIT ICC model to include additional risk factors for poor birth outcomes, such as domestic violence, food insecurity, obesity, or substance abuse. However, adding additional screening targets could limit the feasibility of screening and intervention in the context of the well-child visit. The use of the WCV is one of many strategies that providers may use to deliver the full breadth of comprehensive interconception care that women should receive. Future effectiveness studies are needed to assess rates of prematurity and other birth outcomes in populations who received interconception care through the IMPLICIT ICC model, especially at sites who have implemented the model for several years, to inform the growing literature on preconception care.

Study Design: Descriptive statistics; Feasibility study

Setting: Eleven eastern US family medicine residency programs

Population of Focus: Mothers accompanying their babies at well-child checkups

Sample Size: Varies across sites

Age Range: <15--≥24