BPS2010-2
AMCHP Best Practice Submission 2010
1. What is the name of your practice or program?
Healthy Start, Inc.
2. Please provide a description/abstract of the practice you are submitting in 200 words
or less which address the following 1.) Project goals 2.) Activities undertaken to develop
the practice 3.) How was project/practice success measured 4.) What makes this a
remarkable practice, and 5.) How will others benefit from learning about this practice?
1.) The project goal was to have a system that would prompt our home visiting staff to screen
our program participants for postpartum depression during the interconceptional period.
Screening at enrollment into the program and right after delivery was automatic for them. But
there was no event to let them know it was time to screen the participants at any time after
that. Because postpartum depression can occur anytime within the first year after birth, we knew
that we might be missing opportunities to detect it without this interconceptional screening. 2.)
The activity undertaken was development of a tickler system which is a simple file that provides
notification of when the participant's next depression screen is due. After the participant fills out
her first screen when she is enrolled, the data is entered into the database. Based on her score,
it is determined when she should be screened next. There has been an algorithm in use for this
purpose for about 6 years at this agency. For example, if the participant's score on the
Edinburgh Postnatal Depression Scale (EPDS) is less than 9, the participant will not be screened
for another 6 months, unless she gives birth before that. The staff person entering the data from
the screen would determine what week is 6 months away, write that week and the participant's
name on a blank depression screen, and put it into the tickler folder dated that week. During the
case review preceding that week, the staff person in charge of handing out the needed forms for
that week's home visits also takes the blank depression screens and hands those out as well,
prompting the home visitor to screen the participant. 3.) Success was measured by comparing
how many interconceptional screens were done before the system was implemented to how
many were done after. 4.) It yields valuable information without using a computer program, or
taking much time after it is set up. 5.)The benefit is that women will be identified more often and
get the attention needed for what is a serious public health problem.
3. What is the primary population focus for your best practice? Check all that apply.
Adolescents
Women
4. Please provide information about the location of the practice - i.e., is the practice statewide or in one area of the state/community? What is the approximate sample size?
The location is a maternal-child health agency serving Fayette County in Southwest
Pennsylvania. The sample size was 209.
5. Describe the audience or practitioner who would benefit from learning about this
practice.
Anyone who is screening women for postpartum depression would benefit. The numbers of
practitioners doing screening for depression will be increasing due to the MOTHERS Act included
in the new health care reform act.
6. What is the primary issue focus(es) for your best practice? Check all that apply.
Access to Health Care
Health Inequity/Disparities
Mental Health
Data, Assessment, &
Health Promotion
Prenatal Care
Evaluation
Health Screening
Reproductive Health
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7. Please describe the specific need for this practice, i.e., what data or evidence do you
have regarding your target population that shows this is a problem? Cite specific
literature and local or state data as appropriate.
Healthy Start participants have a higher percentage of postpartum depression than the general
population due to factors like poverty, low social support, and barriers to health care. The
percentage of postpartum depression in the general population is around 15%, however, in our
population it is around 40%.
8. What are the overall goals and key objectives of your practice?
Goal: To identify those women whose postpartum depression may have manifested later in the
interconceptional period. Objectives: 1) To close the gap in screening our participants for
postpartum depression. 2) To monitor the mother's health so that she is healthy before she
becomes pregnant again. 3) To facilitate access to mental health care.
DESIGN
9. What is the theoretical foundation (e.g., Social Change Theory) for your practice? List
any theories used, and explain how they were applied. If multiple theories were used,
explain how they fit together to form the basis of your practice.
The CDC notes that the American College of Obstetricians and Gynecologists recommends that
doctors screen all new moms for postpartum depression four to six weeks after birth. Postpartum
depression (PPD) is a serious medical condition that can develop during the first year after
childbirth, usually peaking 3 to 6 months after delivery. Postpartum depression affects both
mother and baby, interfering with a mother's ability to function, mother-baby bonding, and child
development and safety. Depression rates among low-income pregnant women may be as high
as 27.6%. (Hobfoll SE, Ritter C, Lavin J, et al: Depression prevalence and incidence among
inner-city pregnant and postpartum women. Journal of Consulting and Clinical Psychology
63:445–453, 1995) A striking 14.5% of women experience a new episode of depression during
pregnancy or the first three months after delivery. (Gaynes B, Gavin N, Meltzer-Brody S, et al:
Perinatal depression: prevalence, screening accuracy, and screening outcomes; in Evidence
Report/Technology Assessment. Rockville, MD, Agency for Healthcare Research and Quality,
2005)
10. Did you base your practice on existing tools (guidelines, protocols, models or
standards such as Bright Futures guidelines)? If so, please specify which ones and
explain how they were used in the practice.
We use the Edinburgh Postpartum Depression Scale which has been validated for many different
populations. We also use an algorithm based on information from "Algorithm for Clinical
Decisions" developed by Dr. Katherine Wisner at Western Psychiatric Institute and Clinic. This
algorithm guides the staff to what to do next with a participant based on the score of her
Edinburgh screening.
11. How did you adapt these tools to your practice? Be specific about changes to the
model that were made, portions that were not used, and why adaptations were made.
The algorithm was enhanced to show the staff if they needed to do an intervention while they
were still in the home with the participant. Examples of such interventions would be doing a
suicide risk assessment, or immediately making a referral to a mental health provider.
12. What was your process to incorporate peer/ stakeholder input and lessons learned
throughout implementation?
This practice was developed as a project for the Interconceptional Care Learning Collaborative in
which all of the Healthy Start grantees are taking part. This project was done for Cycle 1 which
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ended in June 2010 with a conference where posters were presented on each grantee's change
project. During the cycle, there were conference calls between the groups that had similar
projects in order to exchange information about the process and the projects each was doing.
The information is also being posted on a website exclusive to the collaborative members.
13. Describe your evaluation process, including short term and long term outcomes that
were measured. Explain the methods of evaluation such as whether you used a control
group, how people were selected to participate in the practice, and the potential biases of
this process.
The outcomes that were measured were the increase in the number of interconceptional
participants who were screened for depression. It also involved feedback from the staff that
actually used the system.
14. Does your best practice relate to any of the 18 National Title V/MCH Block Grant
Performance Measures? Check all that apply.
N/A
IMPLEMENTATION
15. What was the time frame for your practice (e.g., time from implementation to
completion or is it ongoing)?
The time frame was from Sept. 2009 until April 2010. The system is ongoing as a permanent
protocol.
16. What did your practice cost in terms of resources (e.g, type/amount of personnel,
funds, supplies/materials, etc.)? Include a calculation of cost per client.
The only cost involved in the practice was for the additional files to set up the tickler system and
the time that the employees used to count the participants screened.
17. If this practice involved collaboration, who were your partners?
There was no collaboration with any partner.
18. Were there other factors in your state or community that influenced the launch of this
practice- e.g., legislation, new leadership, release of data, etc.? Please describe how
these contributed.
There were no other factors outside the agency.
19. Was the practice implemented as intended? What challenges did you face in
implementing your practice?
Yes. The biggest challenge was gathering the data and the time it involved.
20. How did you overcome the challenges you faced in implementing your practice?
We made the system a priority and set aside a few activities to make the time. We knew that it
was only temporary and would save time in the future.
OUTCOMES
21. What data did you collect to measure the outcomes of your practice?
We counted the number of interconceptional participants who had been screened prior to the
tickler system being implemented and compared it to the number screened after
implementation.
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22. What were the results of your practice? Be specific, including both short-term and
long term outcomes. If available, please provide data (e.g., through use of control group,
etc) demonstrating that outcomes were achieved by your practice and not due to outside
factors.
Yes. There was peer review at the conference that took place at the end of the cycle. The project
and the results were presented via poster session.
23. Was there an expert/peer review process that determined your practice to have
significant evidence of effectiveness (e.g., peer-reviewed journal, conference
presentations, etc)? If YES, please describe process:
Yes
There was peer review at the conference that took place at the end of the cycle. The project and
the results were presented via poster session.
24. Has your practice been replicated (e.g., in other settings and/or with other
populations)?
Yes. The process was replicated in the main office of the organization in Allegheny County.
25. What would you keep and what would you change if you were creating this practice
now?
We would keep everything the same because it is working as was intended.
FOLLOW-UP
26. Is there a sustainability plan in place? Do you know the next steps for your practice?
If YES, please describe:
Yes. The system will be maintained by the staff, and even if someone leaves the agency, enough
people know how it works and are involved in using it that it would not interrupt the system.
27. What products/resources resulted from your practice (e.g. website, published?)
The process and results were posted on the website provided for the Interconceptional Care
Learning Collaborative as a resource for other agencies.
28. How would you tell other people about this practice, i.e., what is your "take away"
message?
We have to remain vigilant about postpartum depression and how it is affecting the vulnerable
population we serve. Using this system is one way to accomplish that goal. It is not enough to
screen once immediately after the birth of a child. Depression may set in up to a year after that.
This system provides a reminder to screen the mother again at a later date and possibly catch
the depressive episode then.
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