ONE KEY QUESTION®

An initiative of the

Oregon Foundation for Reproductive Health

ONE KEY QUESTION® IN PRIMARY CARE

A simple screening question to facilitate a conversation with your patient regarding her pregnancy intention

Designed to help you ID the preventive reproductive health care needs of your patient’s

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FACTS Most American families want two children.

The average woman is fertile for 39 years and spends 3 decades trying to avoid an unintended pregnancy. She spends about 5 years pregnant, postpartum or trying to become pregnant.

Currently, about half (51%) of the 6.6 million pregnancies in the United States each year are unintended

By age 45, more than half of all American women will have experienced an unintended pregnancy

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Guttmacher Institute- Unintended Pregnancy in the United States- Jan 2015

In Oregon, 2011:

43.5% of pregnancies were unintended

55.7% of all deliveries were paid for by

Medicaid

48.7% of women did not take a prenatal or

multivitamin prior to conceiving

PRAMS 2011: Oregon Department of Human Services, Public Health Division, Pregnancy Risk

Assessment Monitoring System

MORE FACTS

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UNINTENDED PREGNANCY IS ASSOCIATED WITH…

Health problems for both mother and infant including:

Preterm birth, low birth weight, increased infant mortality

Delayed prenatal care

Increased depression, anxiety & physical abuse for mother

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IN REALITY…

Most unintended pregnancies are unwanted or mistimed, and most could be prevented with better access to contraception

Some unintended pregnancies are wanted, and could be better prepared for with access to preconception care

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CONTRACEPTION WORKS

7 Guttmacher Institute: Unintended Pregnancy in the United States. December 2013

35% of

women at risk

of becoming

pregnancy

have nonuse

or inconsistent

use of birth

control

OUR SOLUTION

Ask all women of reproductive-age One Key Question® as a routine part of primary care:

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PREGNANCY INTENTION SCREENING

One Key Question® is a screening tool to help identify women in need of preventive reproductive health care

framed as “Would you like..” to hear your patient’s own goals for her health

followed by evidenced-based care can have a big impact on your patient population health

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PREVENTIVE REPRODUCTIVE HEALTH

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Contraception and preconception care

offered in a proactive and routine way!

THE ONE KEY QUESTION® ALGORITHM

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IF YOUR PATIENT ANSWERS ‘YES’

Preconception Care

Screen for conditions that can affect pregnancy

Review medications

Recommend Folic Acid

Talk about the benefits of birth spacing

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ADDITIONAL PRECONCEPTION ADVICE

Advice to reduce/eliminate alcohol, tobacco, street drugs

Review prescribed and OTC medications, supplements, herbs

Screen for STIs, diabetes, hypertension

Check if immunizations are up to date

Recommend healthy diet, daily exercise, sleep, stress reduction

Advise a dental cleaning/check up

Screen for risk of intimate partner violence

Establish relationship with primary care provider

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IF YOUR PATIENT ANSWERS ‘NO’

Contraceptive Services

Ask if she is currently using a birth control method

Check on her satisfaction with current method

Offer more options, including long-acting reversible contraceptives (IUD, Implant)

Include information on emergency contraception

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CONTRACEPTION BASICS

Many women use short-term or less reliable contraception because it’s what they are used to

The best method for women usually changes with time or with pregnancy/birth

There are great long-acting reversible contraception (LARC) methods that would be ideal for many women

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Protect against pregnancy for multiple years

Reduction of user-error: no need for woman to do anything for them to work

More effective than other methods with fewer side effects

Women can have them removed anytime they want with rapid return to fertility

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LARC’S

LARC’S

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Intrauterine Devices (IUDs)

Paragard = 12 years

(no hormones)

Mirena = 5 years

Skyla= 3 years

Implantables

Implanon = 3 years

Nexplanon = 3 years

‘UNSURE’ OR ‘OK EITHER WAY’

Follow up

Offer a combination of contraception & preconception care

Discuss relevant issues

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‘UNSURE’ OR ‘OK EITHER WAY’

Many women are unsure or ambivalent, especially if they’ve never been asked! You can start a conversation:

Is now the right time?

Do you have the resources you need for another child (money, time, child care, space)?

How would having another child impact family work plans, education plans, financial status?

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FOLLOW UP QUESTIONS

Use the 1-10 scale to gauge ambivalence or ask “How important is it to you to prevent pregnancy?”

•“Why would you say you aren’t a lower number?”

•“Why do you think your number might not be higher?”

•“I hear you have mixed feelings, but it’s something you’re thinking about. How can I help?”

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FOLLOW UP RESPONSES:

“I would recommend you chose a contraceptive method to protect against pregnancy until you are sure.”

“I want you to know in a year’s time- 85 out of 100 women who have unprotected sex will become pregnant.

“What would you like to do?”

“How can I help you reach your goal?”

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Risky Assumptions by Providers:

“This person should not become pregnant – I won’t offer preconception care”

“This patient is getting reproductive health care somewhere else”

“This patient knows how to use their birth control correctly”

UNDERSTANDING YOUR PATIENTS GOALS WILL HELP YOU Identify THE PREVENTIVE REPRODUCTIVE SERVICES THEY NEED.

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OVERCOMING BARRIERS

Time intensive to ask:

“There is not enough time in a PC visit to address RH needs”

Our pilot showed:

OKQ is feasible in a PC visit and acceptable to patients to ask- even at ‘non reproductive health visit.

Only about 30% of women asked will need f/u care.

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OVERCOMING BARRIERS

ONE KEY QUESTION® OUTCOMES

@ Community Health Clinics:

30% of women needed follow-up with contraception or preconception care

70% did not require any follow-up services

@ Public Health Clinics:

60% of women were happy with their current method of contraception

23% received new contraception services

12% were given preconception care and advised to start folic acid

WHY PRIMARY CARE?

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Screening for pregnancy intention and providing follow-up services is essential for primary care to manage chronic conditions before conception

Pregnancy Intention can change for women throughout the year – so ask often, not only at Well-Woman visits

The ACA now requires insurance to cover preventive care for women including all FDA approved birth control, some preconception care & folic acid, prenatal care, and more!

OTHER SCREENINGS IN PRIMARY CARE

Established Indicators of High Quality Care include

Depression screening (PSQ-2 and 9)

Alcohol misuse (SBIRT)

Cervical cancer screenings (Paps)

Breast cancer screenings (exams, mammography)

Blood pressure

Diabetes screening (blood glucose and HgbA1c)

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LIFETIME RISK

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ACHIEVE THE “TRIPLE AIM”

Improve health outcomes

Improve the experience of care (quality and satisfaction)

Reduce per capita costs

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PCPCH METRIC

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Patient Centered Primary Care Home (PCPCH) standard

for age and gender appropriate services that meet the

HRSA-recommended preventive services for women:

Contraceptive methods and counseling

Folic Acid use

“Screening methods described by the One Key Question®

Initiative are adequate to meet these services”

CCO METRIC

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“Effective contraception among women at risk

of unintended pregnancy”

Incentivized metric for Coordinated Care Organizations

for 2015!

Oregon is 1st in the nation to adopt a preventive

reproductive health metric!

ONE KEY QUESTION® IS DESIGNED TO…

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Start a conversation about preventive reproductive health in primary care

Prevent pregnancies that are unwanted or mistimed

Increase the proportion of pregnancies that are better prepared for.

OFRH SUPPORT

Implementation Manual Clinic and Staff inventory

Various algorithms for screening

Custom Consultations Clinic Flow, Data Collection

Additional trainings for providers and team

OKQ patient brochures and posters

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CONTACT US

Oregon Foundation for Reproductive Health

Michele Stranger Hunter- Executive Director

Sharon Meieran, MD, JD- Co Medical Director

Julia Epstein, NP- Co- Medical Director

Hannah Rosenau- Senior Policy & Access Coordinator

info@onekeyquestion.org

Follow us on Facebook and Twitter: Oregon RH

www.onekeyquestion.org

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PREGNANCY INTENTION SCREENING USING:

ONE KEY QUESTION

Jennifer Johnstun, RN

– PrimaryHealth CCO

Maggie Sullivan, MPH – Health Care Coalition of

So. Oregon

Belle Shepherd, MPH

- OHA

FORMATION OF THE CONSORTIUM

1990s - Jackson County Perinatal Task Force formed by Jackson County Medical Director

2008 - Josephine County Perinatal Task Force formed by Josephine County Public Health Manager

2012 – Southern Oregon Perinatal Task Force forms, merging efforts of both counties, and relationships with Managed Care Organizations continue through formation of CCOs

ORGANIZATIONS IN THE CONSORTIUM

Public Health – Jackson and Josephine

CCOs – Allcare, Jackson Care Connect, PrimaryHealth

FQHCs – Siskiyou Community Health Center, La Clinica, Rogue Community Health

Other partners: Women’s Health Center, Siskiyou Pediatrics, Asante Health Systems, DCOs and Dentists, Family Nurturing Center, Drug and Alcohol clinics, Head Start and Early Head Start

MISSION STATEMENT

To improve the health and well-being of pregnant women, infants, and young children by empowering women and families to make healthier choices for

themselves and their babies, before, during and after pregnancy.

(Adopted January 2013)

FUNDING RECEIVED FROM OHA, COMMUNITY PREVENTION GRANT

Fiscal Agent & Project Direction-Funded 10/2013:

Jackson County Public Health

Project Management:

Health Care Coalition of Southern Oregon

A 501(c)-3 non-profit organization made up of public health agencies & community health centers in Jackson, Josephine & Douglas Counties

HEALTH OUTCOME MEASURES TO BE TRACKED

The steering committee for the Community Prevention Grant determined the following outcome measures:

Early Entry into Pre-natal Care

Teen Pregnancy Rate

Teen Birth Rate

Unintended Pregnancy Rate

Contraceptive Use Rate

ONE KEY QUESTION (OKQ) IMPLEMENTATION

Steering committee formed to:

Identify champion agencies to start screening

Plan for training and education efforts

Review materials to be used

Address implementation problems

ROUTINELY SCREEN WOMEN FOR THEIR PREGNANCY INTENTIONS (ALIGNED WITH OHA STRATEGY #1)

Paper form used by WIC, MIECHV Programs:

WORK UNDERWAY TO EMBED OKQ IN OCHIN/EPIC & OTHER EMR SYSTEMS

Medford FQHC, La Clinica, initiated request to build OKQ algorithm into OCHIN/EPIC.

Work teams provided input on work flow outline (Outside-In, Multnomah Co PH, Wallace Medical Concern, OPCA, La Clinica).

CareOregon donated staff time to assist with build. Build in-process

Other clinics looking at how to embed in their EMRs

Efforts to integrate OKQ with EMRs make it easier for providers to implement an OKQ workflow

OHA STRATEGY #2: REMOVE BARRIERS TO CONTRACEPTION

Education for providers and members regarding OHP’s coverage of all methods of birth control (and how/where to obtain this from CCOs).

Request to local CCOs to provide at least 3-month supply of Birth Control Pills

Client education on effectiveness of methods

STRATEGY #3: IMPROVE AVAILABILITY AND INCREASE REFERRALS FOR LARCS – LONG-ACTING REVERSIBLE CONTRACEPTION

Development of Local Family Planning Referral Grid, with info on where to get contraceptives

Education Materials

Contraceptive Update Training for providers and clinics

Title X

(Title 10)

CCARE OHP Private Ins Sliding Scale Walk-in

Welcome

Methods offered

Ashland Clinic

541-482-9741

99 Central Ave

Ashland, OR 97520

Medford Clinic

541-773-3863

19 Myrtle St

Medford, OR 97504

White City Clinic

541-826-5853

8385 Division Rd

White City, OR 97503

Butte Falls Clinic

541-842-7799

722 Laurel Ave

Buttle Falls, OR 97522

Phoenix Health Center

3617 S. Pacific Hwy

Medford, OR 97501

West Main Health Center

1307 W. Main St.

Medford, OR 97501

Women's Health Center

910 S. Central Ave

Medford, OR 97501

Central Point Health Center

4940 Hamrick Rd.

Central Point, OR 97502

1701 NW Hawthorne Ave

Grants Pass, OR 97526

25647 Redwood Hwy

Cave Junction, OR 97523

Title X (Title 10)

1. Live in Oregon

2. Have income up to:

IUD

Pills

Implants

Ring

Shot

Patch

Condoms

Emergency Contraception

●

● ● ● ● ● ●

● ● ● ● ●

● ● ● ●

●

● ● ● ●

IUD

Pills

Implants

Ring

Shot

Patch

Condoms

Emergency Contraception

For private insurance, call you insurance company, and ask to speak with a representative.

Primary Care - You may have a primary care provider that offers Family Planning Services

● ● ● ●

● ● ● ●

●

Oregon Contraceptive Care (CCARE): CCARE offers free contraceptives, contraceptive counseling and annual exams to women and men who meet financial

guidelines and eligibility requirements listed below:

Family Planning Referral List for Jackson and Josephine Counties

Ring

Pills

Shot

Patch

Condoms

Emergency Contraception

IUD

Pills

Ring

Shot

Patch

Condoms

Emergency Contraception

IUD

Pills

Implants

Ring

Shot

Patch

Condoms

Emergency Contraception

IUD

Pills

Implants

Ring

Shot

Patch

Condoms

Emergency Contraception

Clinic

Jackson County Public Health 541-774-8209

Community Health CenterIUD

Pills

Implants

Ring

Shot

Patch

Condoms

Emergency Contraception

1005 E. Main St

Medford, OR

**Moving in December 2014**

140 S. Holly St.

Medford, OR 97501

715 NW Dimmick St

Grants Pass, OR

● ● ● ● ●

La Clinica 541-618-1300

Planned Parenthood 541-344-9411

Josephine County Public Health 541-474-5325

Siskiyou Community Health Center

541-472-4777

Women's Health Center of Southern Oregon

541-479-8363

Ashland Medford

1532 Siskiyou Blvd. 125 S. Central Ave

Ashland, OR 97520 Medford, OR 97501

Grants Pass

160 Franklin Blvd

Grants Pass, OR 97526

Title X (called "Title Ten") is a Federal Grant Program providing confidential family planning and reproductive health services to low-income, uninsured, and undocumented individuals at

reduced or no cost. Title X Clinics cannot refuse services based on ability to pay, and offer a sliding scale fee based on income. Individuals at or below the federal poverty level pay

nothing.

4. Have a Social Security number (SSN)

If you have health insurance, they MUST cover ALL birth control methods at NO COST to you. If you are uninsured, you may

still qualify for free or low cost birth control under Title X (10) or Ccare, please see guidelines below.

3. Present photo ID

AllCare CCO - 541-471-4106 Jackson Care Connect CCO - 1-855-722-8208 Primary Health of Josephine County CCO - 541-471-4208

1075 SW Grandview Ave Suite 200

Grants Pass, OR 97527

For Oregon Health Plan , contact your Care Coordinated Organization (CCO).

1 $561 $2,4322 $756 $3,2783 $951 $4,123

For each additional person add: $195 $846

Version 3 , update 8/2014

STRATEGY #4: CREATE QUALITY IMPROVEMENT PROCESSES FOR PRECONCEPTION & CONTRACEPTIVE CARE

Initial OKQ Data from WIC was compiled. WIC staff receives data back for QI regularly.

What percent of women not currently on BC were referred for contraception?

What percent of women are taking daily multi-vitamins?

What percent of women receive info on preconception health & primary care?

WIC DATA ( JACKSON COUNTY NOVEMBER 2014 )

WIC DATA “YES”

WIC DATA “NO”

WIC DATA “NO, AND USING BIRTH CONTROL”

STRATEGY #5: BUILD PROVIDER AWARENESS AND CAPACITY FOR EFFECTIVE CONTRACEPTIVE USE

Reproductive Health Update Training - November 13, 2014 –Presented by CARDEA & Dr Deborah Oyer

Plenary Contraceptive Update Attended by 80

Clinical Case Management for Contraceptive Care – Attended by 30 providers

Contraceptive Counseling Session- attended by 30 health workers

IUD Insertion Training – attended by 30 providers

Nexplanon Insertion Training – attended by 25 providers

STRATEGY #6: ENHANCE PARTNERSHIPS WITH LOCAL FAMILY PLANNING CLINICS

Outreach to family Planning clinics – distribution of patient education materials and multi-vitamins

Roll-out of One Key Question at County Health Dept Family Planning Clinics

Family Planning Referral Grid

How do we build motivation to address this? (One Key Question is One More Thing)

How does this fit into each PCPCH’s vision for how they wish to provide care?

How can CCO and clinic priorities align(Ex: Shared Decision Making?)

What did we learn from SBIRT implementation that can help us with rolling out this initiative?

How can we work together as a community of providers to accomplish this?

CONCEPTS FOR CCOS TO CONSIDER