Promising Practices: MAC-IMP at Columbia University Irving Medical Center/New York-Presbyterian Hospital Ambulatory Network

Strategically Identifying and Addressing Needs

One of the foundational components of MAC-IMP’s approach is to identify and streamline services so that families can have their needs met in an accessible way. This family-centered approach seeks to match families with programs that meet their identified needs in addition to provider-identified needs while building relationships that help families seek additional help as concerns arise. Families in pediatric and obstetrics practices are screened for maternal depression (with the Patient Health Questionnaire 9 - PHQ-9), intimate partner violence and social determinants of health (housing, transportation and food insecurities) during each trimester, and in the postnatal and early childhood period. Screenings are completed online, or in person, when possible, prior to the visit, gathering information in advance so that obstetric and pediatric providers can connect with the family during the visit to understand needs.

Additionally, MAC-IMP utilizes the WALLE (Waiting room As a Literacy and Learning Environment) program with waiting room volunteers trained to gather social determinants of health information from families in culturally and linguistically competent ways. They document information within the electronic health record (EHR), and use NowPow, a city-wide online resource system, that is also connected within the EHR, to access and offer services throughout the city. Together, these tools support referrals so that families receive either an electronic prescription with a list of resources, or connections to a community navigator who makes appointments and provides follow up for families with high needs. NowPow also supports referrals to early intervention for young children within the EHR so that providers get updates and information to identify the status of referrals.

Coordination is a critical component of this work. After providers capture screening data and health history in the EHR and refer to services, MAC-IMP program coordinators review information along with provider recommendations to triage resources for families. Using a thorough chart review process and regularly scheduled clinical team meetings, the team works together to determine appropriate referrals using provider information, family goals and knowledge of specific programs both within and external to MAC-IMP. A risk stratification strategy with corresponding bundles of care informs what interventions are best suited for each patient. Interventions available within MAC-IMP include HealthySteps, Community Health Workers (CHW) as well as the EMBRACE (Empowering Mothers Birth Rights through Advocacy, Community and Education) post-partum doula program. CHWs that are shared with community-based organizations are available to support families by connecting them with services. The EHR serves as a formal referral process for tracking to coordinate services.

Using Multi-Generational, Trauma-Informed, Culturally and Linguistically Relevant Approaches

MAC-IMP is part of a culturally diverse community with staff that uses a wealth of resources to communicate and build relationships. New York Presbyterian Hospital hires diverse, multi-lingual staff who represent the cultures of the populations that they serve. When needed, in-person, video, and written translation is available to providers to promote a welcoming environment where they can build relationships with families. Staff access tools, such as an Early Childhood Resource Guide and ongoing training and community partnerships to help them collaborate with families, understand cultures that may be different from their own and learn ways to approach challenging conversations.

Staff at MAC-IMP are well trained in providing mental health and psychosocial supports for families including perinatal mental health. They meet weekly for case discussions, trainings with experts from the field and data review, to assure on-going reflection and skill building. They constantly evaluate their own biases, finding ways to create nonjudgmental environments for children and families to share their needs and concerns. Using a trauma-informed approach, staff acknowledge that families’ challenges are part of larger societal issues and seek to address psychosocial needs that have the potential to improve outcomes. Using open-ended questions that are built into all EMR documentation templates, families can tell their own stories and share their daily lives. This family-centered approach helps build a connection between the provider and the family, while creating a nurturing relationship with the medical home.

Within the primary prevention system, staff share simple, straightforward resources in families’ preferred language. Pregnant people receive ongoing education opportunities to engage in positive parenting and family planning. All staff are trained in evidence-based positive parenting curricula which is complemented by collaborations with HealthySteps psychologists. Combining rich, multi-lingual age-appropriate positive parenting resources and access to the HealthSteps specialists offers families effective parenting strategies. Additionally, for families that have basic needs, MAC-IMP leadership support social workers and community-based organizations (CBO) partnerships to connect clients to resources whether in the clinic or the community. They constantly work on enhancing tools so that staff and partners can support their patients.

The CBO partnerships, which are central to secondary and tertiary prevention, engage in this relationship-based approach to promote wellness. MAC-IMP programs such as the CHW program, HealthySteps, EMBRACE and Practical Resources for Effective Postpartum Parenting (PREPP) use psychosocial approaches to meeting with families and addressing their needs. These programs are built in partnership with local CBOs to improve referrals for psychosocial supports within the community and to support maternal-infant bonding. Through regular case management meetings, partners and staff discuss families’ needs, jointly identify solutions, and streamline services so that families can access the supports they need through the systems organized within MAC-IMP and its partnerships.

The Role of Data within the System

MAC-IMP staff deeply understand the fragile nature of data collection when gathering medical, mental health and psychosocial information from families, particularly in populations with high needs. Therefore, data collection is an ongoing process where providers gather information through screeners, but also within conversations during visits and services with CBO partners. They’ve worked with their EHR and Hospital Analytics team to develop systems within the EHR such as a referral order, EHR reports of patients referred and documentation templates that streamline data collection, exploration and analysis. Data collection systems such as logs of families with higher needs and screening results, are constantly reviewed to identify the best ways to capture and share information to streamline services while meeting privacy and confidentiality requirements of the Health Insurance Portability and Accountability Act (HIPAA).

Alongside the evidence-based screeners that practitioners use, MAC-IMP staff created a mental health referral order so that providers can move families into secondary and tertiary prevention whenever needed. As part of quality improvement efforts, staff also review data analytics regularly to ensure that all families needing services have access. In cases when families may not attend regular visits but have identified needs, these data can highlight gaps in services and allow providers and partners to reach out to re-engage them.

Additionally, data systems such as reports of screening results are analyzed to identify prevalent needs within the population in order to design interventions that might work for families. Overall, this approach towards data systems integrates a culturally competent quality improvement approach which addresses the needs of the population served.

Lessons Learned

There has been a significant cultural shift in pediatrics, obstetrics/gynecology and family practice within the last decade. Providers offer a more holistic approach to identifying and addressing mental health and psychosocial needs that have an impact on health outcomes and each child’s developmental trajectory. MAC-IMP leadership are deeply invested in a coordinated, individualized approach where a team of providers can meet families where they are and connect them to services. Meanwhile, MAC-IMP providers empower families to identify their own needs and set goals that work for them, building their self-advocacy and health literacy skills within the process. Additionally, systems need to be flexible in order to adjust and change with families’ lives. This requires data systems that allow providers ongoing and immediate analysis for planning. As the work grows in sophistication and becomes more streamlined, families can access more psychosocial and mental health supports that lead to better outcomes for their children.

Finally, maintaining strong partnerships with CBOs offers more flexibility in meeting families’ mental health and psychosocial needs and opens doors to identifying individuals with immediate concerns who may not be within the social safety net of the practice. Therefore, creating solutions that can be easily scaled up by CBO partners is a critical need that requires planning and coordination. New York-Presbyterian Hospital and Columbia University have made a major investment in the psychosocial and mental health services that MAC-IMP offers to the community; yet more funding streams are needed to support this kind of work. Outside funding sources support start-up for these projects, yet sustainability requires ongoing advocacy for improved funding by Medicaid and other insurance systems. Additionally, social service organizations need additional funding to be viable resources for children and families.