Literature Collection

The United States is facing a maternal health crisis with increasing rates of severe maternal morbidity and mortality. To improve maternal health and promote health equity, the authors developed a novel 2-generation model of postpartum and pediatric care. This article describes the Two-Generation Clinic (Two-Gen) and model of care. The model combines a dyadic strategy for simultaneous maternal and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social service needs of families. The transdisciplinary team includes primary care physicians, nurse practitioners, psychiatrists, obstetrician-gynecologists, social workers, care navigators, and lactation specialists. Dyad clinic visits are coscheduled (at the same time) and colocated (in the same examination room) with the same primary care provider. In the Two-Gen, the majority (89%) of the mothers self-identify as racial and ethnic minorities. More than 40% have a mental health diagnosis. Almost all mothers (97.8%) completed mental health screenings, >50.0% have received counseling from a social worker, 17.2% had a visit with a psychiatrist, and 50.0% received lactation counseling. Over 80% of the children were up to date with their well-child visits and immunizations. The Two-Gen is a promising model of care that has the potential to inform the design of postpartum care models and promote health equity in communities with the highest maternal health disparities.

BACKGROUND: Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD. METHODS: This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes. DISCUSSION: This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.

This study evaluates the effectiveness of an early childhood tele-education program in preparing community pediatric clinicians to manage developmental and mental health disorders in young children. Community pediatric clinicians from rural, underserved, or school-based health center practices in the mid-Atlantic region participated in a weekly tele-education videoconference. There was a significant knowledge gain evidenced by the percentage of questions answered correctly from pre- to post- didactic exposure (P < .001). Participants reported an increase in knowledge from pre- (P < .001) and in confidence from pre- to post- participation (P < .001). Practice management changes demonstrated an encouraging trend toward managing patients in the Medical Home, as compared with immediately deferring to specialists following participation. This early childhood tele-education videoconferencing program is a promising response to the urgent need to confidently increase the role of pediatricians in the provision of care for childhood developmental and mental health disorders.

BACKGROUND: Mood and anxiety disorders affect one in 5 perinatal individuals and are undertreated. While professional organizations and policy makers recommend that obstetric practices screen for, assess and treat mood and anxiety disorders, multi-level barriers to doing so exist. To help obstetric practices implement the recommended standard of care, we developed implementation assistance, an approach to guide practices on how to integrate screening, assessment, and treatment of mood and anxiety disorders into the obstetric practice workflow. To teach obstetric care clinicians how to treat perinatal mood and anxiety disorders, we also developed an e-learning course and toolkit. OBJECTIVE: Evaluate the extent to which 1) implementation assistance + e-learning/toolkit, and 2) e-learning/toolkit alone improved the rates and quality of care for perinatal mood and anxiety disorders in obstetric practices, as compared to usual care. STUDY DESIGN: We conducted a cluster randomized controlled trial involving 13 obstetric practices across the United States (US). Using 2:2:1 randomization, 13 obstetric practices were assigned to 1) implementation assistance + e-learning/toolkit (n=5), 2) e-learning/toolkit alone (n=5), or 3) usual care (n=3). We measured obstetric care clinicians' quality of care for perinatal mood and anxiety disorders (as measured by medical record documentation of screening, assessment, treatment initiation, and monitoring) documented in patient charts (n=1040). Effectiveness was assessed using multilevel generalized linear mixed models, accounting for clustering of repeated measurements (n=2, i.e., pre and post) within obstetric care clinicians' patient charts (n=40) nested within practices (n=13). Intention-to-treat and per-protocol analyses were conducted. RESULTS: At baseline, no significant differences were observed among the 3 groups regarding documented mental health screening. Chart abstraction at 8 months post-training revealed a significant increase in recommended bipolar disorder screening only among the practices that received the implementation plus e-learning/toolkit (from 0.0% to 30.0%; p=.017). Practices receiving the e-learning/toolkit alone or usual care continued to not screen for bipolar disorder. Documented screening for anxiety also increased in the implementation + e-learning/toolkit group (from 0.5% to 40.2%), however, it did not reach statistical significance when compared to the other groups (P=.09). A significant increase in documented post-traumatic stress disorder (PTSD) screening was observed among practices receiving the implementation plus e-learning/toolkit (0.0% to 30.0%; P=.018). The quality-of-care score in the implementation + e-learning toolkit group increased from 20.5 at baseline to 42.8 at follow-up and was significantly different from both the e-learning/toolkit alone group (P=.02) and the usual care group (P=.03). At 8 months post-training, the implementation + e-learning/toolkit group had higher mean provider readiness scores than the other 2 groups for documentation of screening, assessment, and monitoring. However, documentation of treatment was the only component that reached statistical significance (P=.025). CONCLUSION: Among the practices that followed the implementation protocols, implementation assistance + e-learning/toolkit was effective in improving rates of screening for bipolar disorder, anxiety, and PTSD. However, 3 of the 5 practices did not follow the implementation protocols, suggesting that the intensity of the implementation needs to be tailored based on practice readiness for implementation.

PURPOSE OF REVIEW: Peripheral artery disease (PAD) is a growing global epidemic. Women with PAD are at elevated risk of experiencing psychosocial stressors that influence the diagnosis, management, and course of their illness due to unique sex- and gender-based factors. RECENT FINDINGS: We review existing evidence for increased psychosocial risk in women with PAD with a focus on mood disorders, chronic stress, pain experiences, substance use disorders, health behaviors and illness perceptions, and healthcare access. We discuss how these factors exacerbate PAD symptomatology and lead to adverse outcomes. Existing gaps in women's vascular care are reviewed and potential solutions to bridge these gaps through psychosocial care integration are proposed. Current care paradigms for women's vascular care do not adequately screen for and address psychosocial comorbidities. Clinician education, integration of evidence-based psychological care strategies, implementation of workflows for the management of individuals with PAD and mental health comorbidities, reform to reimbursement structures, and further advocacy are needed in this space. This review provides a construct for integrated behavioral health care for women with PAD and advocates for further integration of care.