Community Health Internship

Community Health Internship
Report and Documentation

By John Perkins, Ph.D


1999 John Perkins


Submitted to:

Judy Canfield, RNC, MS,
University of Washington Medical Center

And

Union Institute

August, 1996

Introduction and Background

August 1, 1996
--The numbers are in for 1994 and Washington State leads the nation with the lowest infant mortality rates of 5.4 infants per 1000 live births compared to the nation's highest rate of 20.1 deaths per 1000 live births in Washington DC.1 The two Washingtons are at polar opposites, though in 1988 the rates for poor women of African American or Native American heritage in Washington state's most populous area, King county and the city of Seattle, rivaled those of the "other" Washington. I put a "dateline" at the top of the paragraph to symbolize the press conference held by the Seattle-King County to discuss the factors contributing to the dramatic improvements in the infant mortality rates.

A Community Responds

Though I did not know it at that time, I have been a part of this exciting story since 1991 when I attended the first community-wide conference convened to build an action plan to deal with the high number of infant deaths.

In 1990, when his staff first brought him the statistics on Seattle's infant mortality for 1988, Mayor Norm Rice asked them what they intended to suggest as a solution. His staff had none, so he sent them back with instructions to never bring him bad news without a plan of what to do.2

Responding to this sense of urgency, Kathy Carson at the Seattle-King County Department of Public Health .i.(S-KC DOPH); quickly hired two outreach workers hired and working before the conference. Outreach workers find pregnant women in poor communities and make sure they get proper medical attention and refer them to the community resources they might need. Five agencies agreed to have outreach workers: Seattle Indian Health Board, People of Color Against AIDS Network .i.(POCAAN);, Street Outreach Services .i.(SOS), Yesler Terrace Health Clinic and the Seattle-King County Department of Public Health.

The November 2, 1991 conference, convened by Dr. Edward Marcuse of Children's Hospital; Elizabeth Thomas, a clinical supervisor at the Odessa Brown children's clinic; and Dorothy Mann and Neal Adams from Region X of the US Department of Health and Human Services. I attended out of personal interest in medical care as the center for activism in the nineties. I also had been interested in whether the conference would reference studies like the Tuskegee Experiments as a source of poor people's mistrust of the medical care system. About 250 people spent the day in break-out sessions brainstorming what needed to be done. I was a little surprised by the action focus, and even more surprised a year later at a follow-up conference, when many of the action steps had been accomplished or begun.

Origins of this Internship

I have been involved with the infant mortality prevention issue in Seattle since 1991. I attended both of the conferences and have served as a speaker with the Infant Mortality Prevention Project Speaker's Bureau organized by the Yesler Terrace Health Clinic. In September of 1994, I painted a compelling picture of the impact smoking has on infant mortality and morbidity at the Fetal Alcohol Syndrome in Communities of Color conference. Also at this conference, I co-facilitated portions of a two-day conference on Fetal Alcohol Syndrome .i.(FAS); in Communities of Color. My co-facilitator, Andrea Allen-Barnes, showed me a videotape she had made as a routine part of her job as an infant mortality outreach worker in Seattle.

One of Andrea's clients innocently asked her to videotape the birth of her baby as a memento. Instead, Andrea's videotape documented her client's unprofessional treatment from medical staff at the University of Washington Medical Center.

In January 1995 the UWMC and outreach workers began serious discussions about ways to improve customer service in the Maternity and Infant Care Clinic (MICC). Andrea invited me to be part of these talks because of my knowledge of group dynamics. I accepted and included this project as one of my internships.

I wish I could go into greater detail about every aspect of this experience, but that type of report is more appropriate for a dissertation than the documentation of the completion of my internship hours.3

The sections which follow are from a grant proposal I wrote describing this project. In the appendix, I include the description of this internship from my Learning Agreement (the document which defines my program) and sample documents from each of the five major goals of this collaboration.

1 American Academy of Pediatrics, available on the Internet.

2 June Beleford, personal communication, 1995.

3 Degree requirements at Union require spending 500 hours in an internship. This is one of two in my program and I estimate I will have spent 800 on this internship by March 30, 1997.



The Grant Application


Note: This slightly edited grant proposal I wrote as part of my Agency's grant application for prevention funds. Submitted October 1995 to the King County Division of Alcohol and Substance Abuse Services.

Preventing Infant Mortality and Morbidity Due to Mother's Drug Abuse During Pregnancy

(ATOD Prevention Strategy: Preventing the Use of Alcohol, Nicotine and Other Drugs During Pregnancy)

Statement of the Issues

The opening sentence of the report from the first Infant Mortality Conference held November 2,1991 summarized the issue of infant mortality in Seattle:

One morning in early 1990, the people of Seattle awoke to headlines announcing that their city, widely renowned for its "livability", had registered the second highest infant mortality rate in the nation for African Americans during the previous year."1

Infant mortality among African and Native American infants had become a local health priority as well as a national one. The full report from the Department of Health and Human Services in 1990 detailing the Health People 2000 goals lamented that the high mortality and morbidity rates for black and Native American babies kept this country from reaching interim target goals for the health of mothers and infants. For example, the Healthy People 2000 goal of 90 percent of pregnant women receiving pre-natal care in the first trimester will never be reached if the African American, Native American and Hispanic American rates remain at the their current levels of 61 percent.2

Due to the advice, suggestions and support of health care providers, many women receiving proper care alter their drug using habits, at least during their pregnancies. They often find the motivation to stabilize their living arrangements, return to school, or deal with abusive relationships. This brings healthy benefits to themselves and their babies and saves society money. When pregnant women delay getting pre-natal care the consequences can be dire, especially if they abuse drugs, which includes self-determined use of over-the-counter and prescription drugs, tobacco, alcohol, marijuana and the so-called "hard drugs". For example, women who smoke during pregnancy give birth to 20 - 30 percent of all low birth weight babies. Each low birth weight baby avoided saves $14,000 to $30,000 in short and long term medical costs. In other words, a low birth weight baby costs 28 to 60 times more than the $500 average cost for providing pre-natal care.3 When all drugs are considered, the General Accounting Office estimates that 42 - 52 percent will require special education costing $750,000 each up to age 18.4

The message has been getting through, slowly. In 1992, 13 percent of the women giving birth in Seattle reported that they smoked, compared to almost 17 percent in 1984.5 Similarly, fetal alcohol syndrome results from a mother drinking alcohol during her pregnancy. Fewer women are reporting drinking during pregnancy; 3.1 percent in 1994 compared to 6.8 percent in 1989.6

However, the Healthy People 2000 report fears that "given recent trends, it is unlikely that the objective of no more that one percent of very low birth weight infants by the year 2000 will be met without a vigorous commitment to provide high quality pre-natal care to all at-risk women."7

This unique collaboration between the University of Washington Medical Center, Yesler Terrace Health Clinic, Central Area Health Clinic, Street Outreach Services, the People of Color Against AIDS Network and the Seattle King County Public Health Department has begun to accelerate the trends for improving the health of Seattle's poorest and most vulnerable citizens.

One of the most important recommendations of the first infant mortality conference, which the final report highlighted with four asterisks for emphasis, read: "break down institutional barriers to care and create a "one stop shopping" approach to service delivery."8 That is exactly what this project has begun.

Through our coordinated efforts we will be able to address these King County priority Risk Factors: Parental Drug use and positive attitudes towards drug use, Early First Use (fetuses have no choice), Family Conflict and Family Management Problems.

Healthy Beliefs and Clear Standards

Bonding: As we learn to trust one another, we have begun to find creative ways of helping substance abusing women bond successfully with health providers. Through this project, the atmosphere at the clinics at the Medical Center has become much friendlier to outreach workers and their clients/patients. Outreach workers have become better advocates for their clients by understanding how the hospital works.

Opportunities: This is a chance for new levels or cooperation between the infant mortality outreach workers and the University. As trust builds, new institutions and organizations will be invited to take part. For example, quarterly meetings are being established with Child Protective Services to review cases and clarify how CPS makes decisions.

Skills and Recognition: Outreach workers will become better advocates of the university hospital and the university will learn how to collaborate with outreach workers to help their poorer clients/patients access available community services. we anticipate having major press releases announcing our conferences.

Gaps in Service and community involvement in ID risk/protective factors.

Seattle held two public conferences to discuss what to do about infant mortality on November 2, 1991 and October 28, 1992. The first conference identified an Action Agenda with 6 Recommendations:

1. Involve the groups that are most at risk in creating solutions to the problem.

2. Increase Outreach among high-risk groups who are not using the community health system.

3. Organize to take legislative action at the local, state and federal levels to enact policies to reduce infant mortality.

4. Strengthen community-based health care delivery and break down the categorical barriers to care.

5. Increase school health services and health education.

6. Increase the cultural competence of providers and make services appropriate to the needs of higher-risk groups.9

Conference sponsors hired the consulting firm of Three River Associates to create an Action Plan Calendar. The second conference convened in 1992, examined progress made after the first conference and considered additional steps which might be taken. In a follow-up memo from the legislative work group two out of five top priority issues included ATOD: prevention of smoking and substance abuse prevention and treatment.10

Project Goals/Objectives

A. describe goals in measurable terms prevent/delays and reduce risk factors.

Since January of 1993, over half of the nearly 4500 labor and delivery patients delivered at the University, have been people of color. The Seattle Infant Mortality Prevention Project Steering Committee includes Dr. Ed Marcuse and Elizabeth Thomas, people involved since 1990 in addressing infant mortality. Representation from the University includes the Chief Operating Officer, Medical Director, and the directors of Patient Care, Social Work, and Maternity and Infant Care Clinic plus hospital social workers and nurses. Completing this committee are outreach workers and their supervisors from the Seattle-King County Department of Public Health, Yesler Terrace Health Clinic, Central Area Health Clinic, Street Outreach Services, and the People of Color Against AIDS Network.

The steering committee has identified 5 goals for 1996-7. (Measurement included in parenthesis.)

1. The project will help the UWMC use the expertise of outreach workers by incorporating them formally into the hospital including providing them with an office, phone and parking places (Measurement: number of days of service outreach workers provide to the clients in the hospital in this role. Staff comments and other qualitative and interview data collected from hospital staff about the usefulness of this approach. Objective name: Interweaving Outreach Workers)

2. The project will complete an introductory videocassette to be shown to expectant mothers and potential maternity patients of the Medical Center. (Measurement: final edited video produced and shown on patient channel in hospital and used in community outreach settings. Objective name: Orientation Video)

3. The University will implementing new procedures which will orient maternity patients to how a teaching hospital functions and help them feel welcomed in the hospital. (Measurement: number of staff trained, and patient feedback on service surveys and in interviews. Objective name: Welcoming Procedures)

4. The project will provide diversity and multi-cultural training for hospital staff. (Measurement: number of staff trained, and patient feedback on service surveys and in interviews. Objective name: Multi-cultural Training)

5. The Project will convening one or two conferences on infant mortality in Seattle. The goals of these conferences will be to a) showcase the progress made in building trust and increasing cooperation between the UWMC and outreach workers; b) to renew our vision for creating the support and caring necessary to eliminate infant mortality in Seattle and c) to inspire other agencies to collaborate and cooperate in reducing infant mortality. (Measurement: conferences occur, and written plans and evaluation forms from the conferences. Objective name: Conferences.)

III. Approaches/Strategies
A. proposed interventions:

1. The project will help the UWMC use the expertise of outreach workers by incorporating them formally into the hospital including providing them with an office, phone and parking places

2. The project will complete an introductory videocassette to be shown to new patients.

3. The project will help the University implement new procedures which will orient maternity patients to how a teaching hospital functions and help them feel welcomed in the hospital.

4. The project will provide diversity and multi-cultural training for hospital staff.

5. The Project will convening one or two conferences on infant mortality in Seattle. The goals of these conferences will be to a) showcase the progress made in building trust and increasing cooperation between the UWMC and outreach workers; b) to renew our vision for creating the support and caring necessary to eliminate infant mortality in Seattle and c) to inspire other agencies to collaborate and cooperate in reducing infant mortality.

B. Estimate of unduplicated numbers served during 1996 and first half of 1997.

The University has between 700 and 800 deliveries a year to women of color (which included African American and Native American mothers and their babies). We estimate that this project will affect the quality of care received of about 1100 to 1200 women of color between January 1, 1996 and June 30, 1997. In addition, many of our project goals will affect other women delivering in the hospital. Total number of delivering mothers served will be around 2400.

Additional high risk pregnant women might be served as other institutions learn about our successes at the planned conferences.

C. outline the ATOD use/abuse specific component of each strategy

Impact on Drug Use Prevention

Objective Name
Specific Impact on ATOD Use, Misuse and Abuse Prevention

1. Interweaving Outreach Workers Poor, possibly drug abusing pregnant women often fear getting care at large hospitals. This objective will help place knowledgeable outreach workers within accessible reach of both hospital personnel and patients. With increased trust, women will be more likely to seek pre-natal care within their first trimester of pregnancy. Also,care providers and outreach workers will be able to support them seeking treatment for their drug abuse. Women often fear that disclosure of their drug abuse might lead to CPS placing their babies into foster care. Outreach workers can help all parties, the mother, hospital, and CPS make clear decisions about when it might be in the best interest of the child to support the mother getting necessary treatment while providing help to keep the family intact. Quite often, the motivation to maintain their families helps women achiever sobriety.

2. Introductory Videotape The UWMC can provide their patients with the highest quality of care when patients cooperate. This tape will help patients understand how a teaching hospital works, their patient rights and who to turn to get their questions or complaints addressed. This tape will be shown on the patient channels at the hospital and used in other contexts to help women understand how the hospital works. We anticipate that this tape will increase the likelihood of women keeping their pre-natal care appointments and better advocates for themselves and their children.
By understanding better what is going on around them, women will be in a better position to make informed choices about their care. Hopefully, this tape will reduce some of the stress they may feel from being in an unfamiliar place and therefore their need to use ATOD to cope with their stress.

3. Welcoming Procedures The videotape and positive and informative first contacts between women and their care providers reinforce each other. This component builds trust and reduces confusion and stress while increasing the probability that women will keep their appointments, cooperate with the medical staff and eliminate or reduce their ATOD use while pregnant.

4. Multi-cultural Training The University acknowledges they must do a better job of helping their staff at all levels understand how a patient's cultural background influences their views of health, illness and what is appropriate care and treatment. For some communities which they serve, past real (or rumored) incidents have bred beliefs within some communities that the staff may be prejudiced about or ignorant of the cultural practices and beliefs of their patients from ethnic communities, especially poor, long-established communities like the African American and Native American communities. The success of this component will have long-term effects of the reputation of the hospital "on the streets" and in Seattle. A positive reputation, combined with positive experiences, will help patients bond with the hospital and accept medical advice to seek treatment or eliminate ATOD use during pregnancy.

5. Conferences Continued efforts to help people understand the health risks posed by ATOD use during pregnancy will be key features of the planned conferences.
.c2.IV. Evaluation plans.
The Steering Committee, as described above, will continue to meet quarterly to review progress towards project and goals and consider corrections and improvements to the project. Minutes will be taken at these meetings and will form a record of the process the project used to reach stated goals.

An independent measure of successful outcomes will be the Vital Statistics maintained for Seattle and King County. Public health statistics to watch for African American and Native American mothers and their infants include: infant mortality and morbidity, percentages of mothers getting early pre-natal care, number of low birth weight babies and percentages of mothers eliminating drugs during their pregnancy.

Measurable outcomes for the five objectives include:

1. Interweaving Outreach Workers. Evaluation measurement: number of days of service outreach workers provide to the clients in the hospital in this role. Staff comments and other qualitative and interview data collected from hospital staff about the usefulness of this approach.

2. Orientation Video. Measurement: final edited video produced and shown on patient's channel in hospital and used in community outreach settings.

3. Welcoming Procedures.
Measurement: number of staff trained, and patient feedback on service surveys and in focus groups and interviews.

4. Multi-cultural Training. Measurement: number of staff trained, and patient feedback on service surveys and in interviews.

5. Conferences. Measurement: conferences occur, plus written plans and evaluation forms from the conferences.

V. Staffing.
John Perkins has been involved with the infant mortality issue in Seattle since 1992. He attended both of the conferences and has been a speaker with the Infant Mortality Speaker's bureau organized by the Yesler Terrace Health Clinic. In September of 1994, he painted a compelling picture of the impact smoking has on infant mortality and morbidity at the Fetal Alcohol Syndrome in Communities of Color conference. In January 1995, Andrea Barnes, an outreach worker from Street Outreach Services invited John to participate in efforts to improve the quality of service at the UWMC and help them create a "one stop shop" hospital for higher risk pregnant women.

#### End of Grant Application ####

Reprise: This is the first year of this collaboration between agencies learning to trust one another. Many unanticipated problems require long hours of meetings to clarify procedures, clear up possible misunderstanding and reach agreement. I no longer work for CYFS and now work for the UWMC on this project. This table shows our progress towards reaching our goals as of August 1, 1996.

.c3.Status of Project Objectives of August 1, 1996.

Objective Name Current Status
1. InterweavingOutreach Workers Begun regular daily duties at the hospital on September 18, 1995. (Sample schedule attached)
2. Introductory Videotape Currently in script development stage. Focus groups conducted for background research. (Executive summary of focus groups attached. Third draft of script written by Charlie Hinckley attached.)
3. Welcoming Procedures Welcoming Steps Prompt Card developed and distributed to nursing staff. (Samples attached.)
4. Multi-cultural Training The UWMC has hired the Cross-Cultural Program at Pacific Medical Center to lead these trainings.

5. Conferences The UWMC held the "Empowering Yourself and Your Patients: The Role of Poverty in Health Management" on May 6, 1996 which I moderated. (Flyer attached).

The "Children's Health Policy Conference" sponsored by Children's Hospital on September 24, 1996, will feature the collaborative work of this Task Force. I assisted in the planning of this hour-long presentation.

1 Children's Hospital, A Better Chance: An Action Plan for Reducing Infant Mortality in Seattle, 1991, p. 1.
2 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, Full Report, DHHS, PHS, 1990, p. 381.
3 US General Accounting Office, Drug-Exposed Infants: A Generation at Risk, Gaithersburd, MD: GAO, 1990, p. 38.
4 Ibid. p. 35
5 Healthy Children, Youth & Families in King County: Data Summary & Guide to Community Planning, Technical Appendix, June 1995, p. 12.
6 Ibid. p. 11.
7 Healthy People 2000, p. 376
8 A Better Chance, p. 30.
9 Ibid.. pp. 18-28.
10 Legislative Work Group Memo, date 1/22/93, p. 2.




Bibliography


Books and Articles

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Drug Exposed Infants: A Generation at Risk.
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Healthy People 2000: National Health Promotion and Disease Prevention Objectives. (1990b). Full Report. Washington, DC: US DHHS, PHS.

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Electronic Sources

American Academy of Pediatrics. (1996, July 20). Annual Summary Finds Infant Mortality Lowest Ever-Abortion Rate and Teen Pregnancy Declining. Available: http://www.aap.org/news/egv/archive/mortal.html.

John Hopkins University. (1996, July 19). Preventing Infant Mortality and Promoting the Health of Pregnant Women, Infants and Children. Available: http://infonet.welch.jhu.edu/~mhim/CHAP1/CHAP1B.HTML.

National Commission to Prevent Infant Mortality. (1996, July 20). Troubling Trends Persist: Shortchanging America's Next Generation. Avialable: http://cuhsla.cpmc.columbia.edu/news/childpov/newi0046.html.

US Department of Health and Human Services. (1996, July 19). Healthy People 2000-a Mid-Decade Review. Available: http://nhic-nt.health.org/fallfoc.htm.

US Department of Health and Human Services. (1996, July 20). Risk and Reality: The Implications of Prenatal Exposure to Alcohol and Other Drugs. Available: http://aspe.os.dhhs.gov/hsp/cyp/drugkids.htm.

Videos

The Doctor, major motion picture.

The First Step: Taking Care of Yourself so You Can Take Care of Your Baby. (1992). Everett, WA: Healthy Mothers, Healthy Babies.

Vital Signs. major motion picture.

Welcome to the University of Texas Health Science Center. (1994). San Antonio, TX: University of Texas Health Science Center.


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