Introduction
Early Start1 is a nationally recognized program designed and implemented in the Kaiser Permanente Northern California (KPNC) Region for early intervention and treatment of substance abuse in pregnant women. Begun in 1990 as a pilot program with Institutional Review Board approval, Early Start is now implemented in more than 90% of KPNC prenatal clinics.
In this way arose the key component of Early Start: making available a licensed substance abuse specialist in the Obstetrics and Gynecology Department for women to see in conjunction with their routine prenatal visits.
Development of the Early Start Program mirrors earlier, more traditional, and holistic ways of caring for women's health. The pioneers of Early Start faced the difficult task of convincing their colleagues and garnering funding to provide innovative specialty care for a marginalized, stigmatized group of women: those who are at risk for using alcohol, tobacco, and other drugs during pregnancy. The visionaries observed that most pregnant woman who were referred from prenatal care to external substance abuse programs for treatment did not seek services. The innovation of Early Start was that it embraced an approach used by the earliest of medicine women—the “wise women” or shamans—who made themselves directly accessible to women. In this way arose the key component of Early Start: making available a licensed substance abuse specialist in the Obstetrics and Gynecology Department for women to see in conjunction with their routine prenatal visits. This model of accessibility provided a welcoming environment that reduced barriers, fear, and stigma and empowered women through listening, building relationships, and supporting them in their personal wisdom, strength, and self-determination toward reclaiming their own health.
This vision and innovation form only part of the story. The founders of Early Start were required to use influence and advocacy to legitimize their vision and to procure sufficient funding to study the benefits of this unique model. The founders were met with many challenges, opposition, and predictions of failure. Fifteen years later, the program serves more than 25,000 women each year and exists in almost every prenatal clinic in KPNC.
As in the traditional “medicine wheel” of many native cultures, four strong elements have worked together in a fluid circle of reciprocity to bring the Early Start program to its full maturity: vision, innovation, influence, and research. The Early Start journey is a microcosm of the journey taken by women to reclaim their health choices and to fulfill their long-standing desire to receive balanced, personalized, evidenced-based care from practitioners who understand women's unique needs.
The Early Years, 1989–1993: A Vision of Preventing Problems
In the late 1980s, frustrated by the large number of babies affected by prenatal substance abuse, two pediatric clinicians, Marc Usatin, MD, and Anne Boddum, NP, envisioned a system that would prevent or reduce neonatal risk of prenatal drug exposure. Ms Boddum received Garfield Grant Foundation funding for her innovative idea to pilot and study the outcomes of a new program, Early Start. Early Start would provide substance abuse treatment to pregnant women by stationing a licensed therapist with substance abuse expertise (the Early Start Specialist) in the prenatal clinic and by integrating standardized risk screening and counseling visits with routine prenatal care.
In 1993, armed with three sets of data—results from the KPNC meconium study (see Sidebar 1 for details), outcomes from the Early Start pilot project (see Sidebar 2 for details),2 and a complementary study of alcohol and drug prevalence in California which included KP hospitals3—Dr Usatin (a TPMG Board member) successfully lobbied his colleagues to expand the Early Start Program to three additional KPNC medical centers and collaborated with the Kaiser Foundation Health Plan (KFHP) to hire a Regional Coordinator, Leslie Lieberman, MSW, to implement the expansion.
Sidebar 1. 1989–1990 Meconium Study.
Faced with disbelief that a drug abuse problem existed among pregnant KP members, Marc Usatin, MD, Neonatolgist, Walnut Creek Medical Center, garnered funds to conduct a KP Region-wide prevalence study of prenatal exposure to illicit drugs. The unpublished study involved testing the meconium of all babies born at >34 weeks' gestation in 1989–90. Facility rates ranged from 1.3% to 4.5% of all newborns who tested positive for an illegal drug; the overall KPNC Regional rate was 3.2%.
Sidebar 2. Pilot Study at Oakland Medical Center.
The Early Start pilot found that most women (93%) diagnosed with substance abuse or chemical dependence agreed to receive follow-up care with the on-site substance abuse specialist. In addition, 69% of women who participated in the pilot stopped using alcohol and drugs by 32 weeks' gestational age, and their babies had substantially lower rates of prematurity, low birth weight, microcephaly, and being small for gestational age. The babies also had fewer neonatal intensive care unit days and lower hospital costs.2
The Middle Years, 1994–2000: A Regional Team and Locally Supported Partnerships
After the initial phase of the expansion, several key factors enabled Early Start to continue its growth in Northern California. By 1994, a KPNC multidisciplinary Early Start Team was in place and included the Regional Director, Champion, and representatives from the Perinatology, Chemical Dependency, and Nursing Departments. This group created a new vision: to make Early Start a regional program available to all pregnant KPNC members. To continue to demonstrate the program's positive impact on outcomes and costs, the group joined forces with the KP Regional Preterm Birth Prevention Program to build a database that could capture data about Early Start participants. Next, an alliance was built with the KPNC Division of Research to enable linkage with other internal data sources that would provide information about birth outcomes. In 1999, the Program received funding from the Kaiser Foundation Research Institute (KFRI) to analyze a data set of records extending from July 1995 through June 1998. This published study4 showed that babies born to substance-abusing women who received Early Start services had better birth outcomes than their counterparts who did not receive Early Start services (see Sidebar 3).
Sidebar 3. Perinatal Outcomes Study.
This study examined records of 6774 KP members who had completed the Early Start (ES) screening questionnaire and delivered babies between 7/95 and 6/98. Four groups were compared: 1) women who were assessed and followed by ES (n = 782), 2) women who were assessed but not followed by ES (n = 348), 3) women who screened positive but received no ES assessment or follow-up (n = 262), and 4) controls who screened negative (n = 5382). Infants of women in group 1 had assisted ventilation rates (1.5%) similar to those of control infants (1.4%) but lower than group 2 (4.0%; p = 0.01) and group 3 (3.1%; p = 0.12). Similar patterns were found for low birthweight and preterm delivery.4
In addition to the vision and research of the middle phase, individual and collective influence played a role in the program's growth between 1994 and 2000. The regional program team received impassioned calls from clinicians who wanted Early Start for their facilities. On their own, these clinicians collected local data, lobbied their facility administrators and colleagues, and scraped together funding to initiate the program when no more regional funds were available. By 2000, Early Start was available at 16 of KPNC's 32 prenatal care sites, yet the funding still came from disparate sources, and the program lacked regional consistency.
The Late Years, 2000–2004: A Vision Accomplished
As the Early Start program passed into its second decade, it won awards from two national organizations for its innovative, effective, evidence-based model (see Sidebar 4), yet work remained to be done to create a regionwide program. Once again, vision, research, innovation, and influence played a role. Several processes worked together synergistically to make this vision a reality.
Sidebar 4. Awards.
In 2000, Early Start was the first recipient of the annual “Models of Excellence in High Risk Care” from The American Medical Group Association and Pfizer, Inc. In 2003, the Program won the Silver Hera Award, which recognizes improvement in women's and children's health outcomes, from the American Association of Health Plans and Wyeth Pharmaceuticals.
Early Start would provide substance abuse treatment to pregnant women by stationing a licensed therapist with substance abuse expertise (the Early Start Specialist) in the prenatal clinic …
In 2001, the regional program team completed a business case which included a cost-benefit analysis of the KFRI research study. The analysis showed that at minimum, Early Start provided a 30% return on investment. Armed with this information, Ruth Shaber, MD, the newly appointed KP Regional Women's Health Leader, endorsed Early Start as one of four women's health programs that should be available throughout KPNC. To get this message out, Dr Shaber conducted multidisciplinary site visits throughout KPNC and strongly encouraged every facility to implement the program. Although this attempt was successful at a handful of facilities, some locations remained unable to commit local funds for Early Start. Meanwhile, the team added clinical excellence and consistency of service delivery to the vision of regionwide access. Toward this goal, Cosette Taillac, LCSW, joined the regional leadership team as the Clinical Coordinator. During that same time, a new Web-based database and electronic charting system, POINT, were developed (Sidebar 5), thus creating more regionwide consistency.
In 2003, several steps led to full regional implementation of Early Start. For the first time, an obstetrician, Nancy Goler, MD, became the KP Regional Medical Director, and the program came under the executive sponsorship of perinatologist Donald Dyson, MD. Together, Drs Dyson and Goler garnered support from their colleagues and presented the compelling business case to KFHP leaders, who agreed, in a historic decision, to fund Early Start as a KP Regional Program.
Conclusion
As 2004 closes, Early Start's 15-year history is clearly a tapestry in which vision, innovation, influence, and research have been woven together to create a whole program. As we look forward, we know that these four elements will continue to help ensure that women have access to all the health care services they need. The transferability of Early Start's innovations are being explored by other KP Regions and have already been adapted by some public-sector programs. Using our POINT database, we routinely produce productivity and quality reports that enable individual sites to improve their efficiency and ultimately to increase access to care for our members. We continue to sponsor trainings for our local team members so that they can effectively implement new sites and increase the consistency of clinical interventions and systems integration at existing sites. As established Early Start sites persevere and flourish and as neighboring KP Regions start planting seeds of their own, the vision of Early Start will continue to grow to meet the needs of women throughout our organization and around the nation.
Early Start's 15-year history is clearly a tapestry in which vision, innovation, influence, and research have been woven together to create a whole program.
Sidebar 5. Point Early Start.
In 2003, the Early Start Program launched POINT EARLY START, a secure, confidential Intranet system that enables authorized users to enter and access screening, assessment, follow-up, and laboratory data on all Early Start patients and to produce productivity and case management reports. With the click of the mouse, a facility can determine what percentage of women who screen positive on the Early Start Questionnaire have been assessed. This information has empowered the local Early Start teams by giving them the data they need to both identify and solve systems issues.
Acknowledgments
The authors thank Donald Dyson, MD, and Ruth Shaber, MD, for their encouragement as well as all Early Start specialists, provider champions, obstetrics and gynecology managers, and Division of Research members who assisted in development of the Early Start Program.
References
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