New York State Drug Court Program: The participant will be able to: Demonstrate the efficacy of patient navigation in order to improve maternal/child health outcomes and parenting skills for the court involved population.

1. A Model Program for Patient
Navigation
Using the Justice System to offer a Health Care
Intervention to Improve Birth Outcomes
Susan Holsapple, PhD
(Boston University)
Mary Jensen, MSW

2. Evaluation
Patient Navigation for Court
Mandated Women

3. Purpose
The purpose of this presentation is to describe a unique and
innovative program that uses an encounter with the justice system to
offer a health care plan for a subset of people going through drug
court. With the application of social theory to clinical practice, an
intervention in the form of patient navigation is developed to meet the
needs of these clients. This presentation will offer a description of the
program and evaluation tools that may be used for standardization
and subsequent replication of this patient navigation model to
improve negative birth outcomes. Constraints on choice may be used
to explain the process of health care decision making for the court
involved population, and patient navigation within the framework of
this model offers a cost-effective means of improving health care
outcomes.

4. Financial Disclosure
We have no relevant financial relationships to
disclose.

5. Objectives
1) To demonstrate the efficacy of patient navigation in order to
improve maternal/child health outcomes and parenting
skills for the court involved population by presenting a
patient navigation project that was successfully piloted in
New York State.
2) To demonstrate the efficacy of patient navigation in order to
improve maternal/child health outcomes and parenting
skills for the court involved population by presenting a
patient navigation project that was successfully piloted in
New York State.
3) Identify the tools that are needed to replicate the model in
other locations.

6. Abstract
Format
Qualitative study – court mandated women who are pregnant or parenting a child < 5 years old
Focus –
methods of access to healthcare, barriers, and interaction with the mainstream health care community.
Goal – Evaluation of a program in order to create a model for patient navigation through the justice system
Methods
Open-ended interviews (audio-taped and transcribed).
Participant observation
-explore treatment modalities options available to high risk pregnant women and their children
Primary data sources
Women (pregnant or parenting), n = 47
Secondary data sources
Infectious disease specialist, n = 1
Navigation Nurse, n = 1
Family practice physician, n =1
Family Court Social Worker, n = 1
Patient Navigation Social Worker, n = 1
The observations took place at three locations: a clinic designed to promote treatment and drug adherence, individual
appointments with the women and their OB/GYN provider, and the Community Treatment Court (SCTC)

7. Abstract
• The purpose of the evaluative study was two-fold; one was to evaluate a
grant supported program that used the justice system to offer patient
navigation services and the second goal was to provide a qualitative
evaluation of the women’s health care experiences as they went through
a court mandated drug program. Primary data was obtained from
interviews with forty-seven program participants (n=47) from March,
2008 until January, 2010, and participant observation was used to explore
treatment modalities and options available to these women. Secondary
data was obtained from program staff as well as a review of the survey
evaluation process by the staff where data was collected through
participant surveys. The findings suggest that poor outcomes for the
women and their children are related to socioeconomic and/or behavioral
barriers that produce difficulties forging successful relationships with
traditional health care providers. When interventions that promote
advocacy and empowerment are in place, there seems to be an
improvement in outcomes for the mothers and their children.

8. Background of Study
Problems:
1) Infant Mortality
Rate of 9.5 for city under study
10.2% of births were low birth weight
Preterm low birth weight was 12.1
2) Infant mortality rates are higher for the group of court
involved women – (as well as having 16% greater chance of
having a premature birth or negative birth outcome)
3) Infant mortality rates are higher for women who report
alcohol abuse, substance abuse, and/or mental illness
(Bada, 2005; Goldenberg, 2000; Zukerman, 1989)

9. Definitions
• Infant Mortality: The death of an infant
before his or her first birthday.
• The infant mortality rate is, by definition, the
number of children dying under a year of age
divided by the number of live births that year.
– Neonatal Deaths: (Further division) Number of
deaths during the first 28 completed days of life
per 1,000 live births in a given year or period.

10. Background
• Wise & Pursley (1992) state that infant
mortality rates are a kind of “social mirror”
that reflect broad inequalities in society and
illuminate the social injustice of communities.

11. Background
Problems:
2) Socioeconomic and Behavioral factors
A major contributing factor to these poor
outcomes of pregnancy is poor
socioeconomic/ behavioral circumstances
affecting the access that vulnerable
populations have to the healthcare system in
this particular county.

12. Court Involved Population
• Often mirrors larger population for poor
outcomes

13. Drug Court
• Drug courts are judicially supervised court dockets
that handle the cases of nonviolent substance
abusing offenders under the adult, juvenile, family
and tribal justice systems.
• Drug courts operate under a specialized model in
which the judiciary, prosecution, defense bar,
probation, law enforcement, mental health, social
service, and treatment communities work together
to help non-violent offenders find restoration in
recovery and become productive citizens. In the USA,
there are currently over 2,140 drug courts
representing all fifty states.

14. Savings
• The cost savings for drug courts are impressive, with cost savings ranging
from nearly $3,000 to over $12,000 per client, additionally
• Those who graduate from drug courts have lower recidivism rates than
offenders who do not go through a drug court program (Roman et al.
2003; Aos et al. 2006).
• This research also shows that because of the integration of numerous
systems, graduates of drug court are able to interact more effectively with
the community when they have access to health care, educational/job
training, and treatment modalities.

15. Lacking
• What was lacking was the health care aspect
of the drug court system.
– Women giving birth on methadone
– Suboxone use (under studied)
• Suboxone, in particular was problematic because it is
under studied in terms of use during pregnancy, clinical
trials are ongoing for neonatal dependency withdrawal
and the use is under reported (Clinicaltrials.gov. 2009.
NCT00521248; McNicholas Laura 2008).
– Created a situation for relapse and difficulty with
program compliance

16. Area Under Study

17. Perfect Opportunity
• In past, focus on reducing infant mortality has
been on prevention and treatment programs
for prenatal care.
• No improvement despite numerous efforts
Solution: Patient Navigation Program

18. New Approach
• The program is titled, “Patient Education and
Navigation for High-Risk Women.” This program
builds upon research done by Olds et al (1986)
that showed evidence for the effectiveness of
nurse home visiting during pregnancy for
improved birth outcomes among disadvantaged
women. The concept of individualized nursing
care is implemented as an intervention in the
form of patient navigation; individualized to meet
the needs of every client.

19. Research Questions
• Does individualized navigation impact the rate
of preterm births?
• Does patient navigation impact the rate of low
birth rates?
• Does patient navigation assist with program
compliance?
• Does patient navigation assist with
socialization and subsequent success?

20. Goal of Study
• Evaluation of program in order to create a
sustainable model of health care through the
justice system
– Socialization considerations rather than
resocialization
To explore the health care experiences of this group of
at-risk women and examine how this group of people
manage to obtain health care within a system that
has historically discriminated against them.

21. Design
• Initial design included only pregnant women
• Design was amended to include women who were
parenting children under the age of five
• Design was amended again to include the stakeholders
The process of data analysis is like a funnel: Things are
open at the beginning (or top) and more directed and
specific at the bottom. The qualitative researcher
plans to use part of the study to learn what the
important questions are. He or she does not assume
that enough is known to recognize important concerns
before undertaking the research. (Bogdan & Biklen,
1998, p.7)

22. Methods
This project was a qualitative evaluative study
using open ended interviews that were
audio-taped and transcribed.
The interview process consisted of two hour
interviews that varied slightly from interview
to interview and built on each other. I
approached “the data with an eye to letting
them teach me what was important”
(Bogdan & Biklen, 1998, p. 32).

23. Methods
• Primary Data Sources
Women (pregnant or parenting), n = 47
Secondary data sources
Infectious disease specialist, n = 1
Navigation Nurse, n = 1
Family practice physician, n =1
Family Court Social Worker, n = 1
Patient Navigation Social Worker, n = 1
The observations took place at three locations:
a clinic designed to promote treatment and
drug adherence, individual appointments with
the women and their OB/GYN provider, and
the Syracuse Community Treatment Court
(SCTC)

24. Profile
• Between 4/01/07 and 4/01/08 there were 192 women
enrolled in the SCTC.
• Approximately 32% of these women were identified as
African-American, 39% were Caucasian, 3% were
Native American, 4% were Hispanic, and 4% were
identified as other race/ethnicities, with the remaining
percent missing this data.
• The women selected for the study roughly reflected
the demographic data for the enrollment in SCTC (15
women African American, 21 women Caucasian)

25. Results
• All participants had a history of child welfare involvement. Over half of the participants had one or
more children in foster care and one or more children living with them. Some spent time in the
foster care system during their youth while others have been separated from their children; many
fall into both categories.
• Transportation was a challenge for participants - few own their own vehicle and public
transportation was difficult to navigate due to bus schedules and the lack of a cross-town bus in
this particular city.
• Safe, stable housing was both difficult to find and financially difficult to attain.
• Participants overwhelmingly stated that they wanted to “become a better parent.” One client
stated: “I messed up with my other kids and lost them to foster care. I don’t want to lose these
kids.”
• Participants desire stable jobs and/or continuing education, and the majority state that they are
“fearful of receiving state benefits” for a long period of time.
• Participants appear resilient despite having faced many challenging and traumatic events.
• Participants are challenged by financial situations, exacerbated by limited education, lack of child
care, difficulty managing medical care, and public benefits.
• Primary source of health care prior to intervention by nurse navigator was the free health clinic.
• Time horizon is different for this group of women and supports the concept of a time horizon that
is differentiated by class (Payne, Ruby, 2006). This group of women tend to think of the “here and
now” and this focus on the present hinders them from seeking preventive health care, especially
prenatal care.

26. Outcomes
• There is little doubt that housing had a positive impact on the participants, but securing permanent
housing was difficult for most of the participants. Proper housing appeared to be related to
compliance with many of the program requirements.
• Participants who were eligible for program housing during treatment found that it positively
affected other areas of their life, such as reducing stress and the ability to remain compliant with
the requirements of the program.
• Participants also stated that being able to keep their children with them made it much easier to
remain compliant. The participants who did have their children with them stated that having a
“room for each child” was the most important aspect of permanent housing and they saw this as
their goal for long term housing options. They felt that by providing a better environment for their
children, this allowed them to provide “the experience of childhood” that many said they had not
experienced in their own lives or with their first set of children.
• Participants related that they would not have been able to manage their health care without the
assistance of the nurse navigator. All pregnant participants interviewed, who used the nurse
navigator, stated that they felt that the nurse was able to “talk to the doctor” for them and “get
me the help I need”.
• All pregnant participants interviewed stated that the nurse navigator was able to get them into
“regular” health care and away from the “poor people’s clinic”. This reference is to the health
clinic that represented the main source of health care delivery for this group of women prior to
intervention by the nurse navigator.

27. Cost
• Published online July 2, 2007
• PEDIATRICS Vol. 120 No. 1 July 2007, pp. e1-
e9 (doi:10.1542/peds.2006-2386)
• Cost of Hospitalization for Preterm and Low Birth Weight Infants in the United
States
Rebecca B. Russell, MSPHa
, Nancy S. Green, MDa,b,c
, Claudia A. Steiner, MD, MPHd
,
Susan Meikle, MD, MSPHd
, Jennifer L. Howse, PhDa
, Karalee Poschman, MPHa
,
Todd Dias, MSa
, Lisa Potetz, MPPa
, Michael J. Davidoff, MPHa
, Karla Damus, PhD,
RNa,c
, Joann R. Petrini, PhD, MPHa,c

28. Cost
• RESULTS. In 2001, 8% (384200) of all 4.6 million infant staysnationwide included a diagnosis
of preterm birth/low birth weight.Costs for these preterm/low birth weight admissions
totaled$5.8 billion, representing 47% of the costs for all infant hospitalizationsand 27% for
all pediatric stays. Preterm/low birth weight infantstays averaged $15100, with a mean
length of stay of 12.9 daysversus $600 and 1.9 days for uncomplicated newborns. Costs
werehighest for extremely preterm infants (<28 weeks’ gestation/birthweight <1000 g),
averaging $65600, and for specific respiratory-relatedcomplications. However, two thirds
of total hospitalizationcosts for preterm birth/low birth weight were for the substantial
number of infants who were not extremely preterm. Of all preterm/lowbirth weight infant
stays, 50% identified private/commercialinsurance as the expected payer, and 42%
designated Medicaid
• CONCLUSIONS. Costs per infant hospitalization were highest forextremely preterm infants,
although the larger number of moderatelypreterm/low birth weight infants contributed
more to the overallcosts. Preterm/low birth weight infants in the United Statesaccount for
half of infant hospitalization costs and one quarterof pediatric costs, suggesting that major
infant and pediatriccost savings could be realized by preventing preterm birth.

29. Discussion
Program’s stated goals:
• We have developed and are using a database to track our test results.
– For Objective #1The clients scored an average of 2.1 (out of a possible 5 points) on the pretest and an
average of 4.5 (out of a possible 5 points) on the posttest. Overall, 83% of participants scored higher on the
posttest than on the pretest.
•
– For Objective # 2, for the time period from 2/1/09 – 2/24/10, 20% (19 out of 97) of the new clients reported
use of folic acid upon initial interview. (See attached survey instrument). From February 8, 2010 through
February 24, 2010, 22 of the current program participants were contacted and asked about their use of folic
acid. 17 women, (77%), report ongoing use of folic acid.
•
– For Objective #3: Since 2/1/09, 19 program participants reported being pregnant. Of this group, all of the
women reported having a medical home; however, due to their expressed dissatisfaction with their care, we
assisted in finding new providers for 2 of the women.
•
– For Objective # 4: For the time period of this report, clients scored an average of 3.0 (out of a possible 5
points) on the pretest and an average of 4.1 (out of a possible 5 points) on the posttest. 67% of participants
scored higher on the posttest than on the pretest.
•
– For Objective #5: At this time, 100% of infant children of the program participants have a medical home.
• Main problem is sustainability

30. Emerging Trends
• This preliminary work has shown that
resocialization efforts often fail because basic
socialization for this group has never
occurred. More work needs to be done in this
area in order to consider these factors of
unequal distribution; taking a
multidimensional approach to health care
disparities in this community would provide
opportunities for successful socialization.

31. Future Model
• By taking a multidimensional approach to the
health disparities and the related outcomes
noted in this group of women, a housing facility
could be developed that would promote the
health care advocacy and socialization process
that is needed for this vulnerable population.
One-on-one mentoring, including
accompaniment to office visits by staff, would
provide one avenue of advocacy that could be
used as a teaching tool for improved outcomes,
further empowerment, and obtaining social
capital.

32. Social Cohesion
• Speer, et al. (2001) found that, social cohesion is related to intrapersonal
empowerment with empowerment being “an intentional ongoing process
centered in the local community, involving mutual respect, critical
reflection, caring, and group participation, through which people lacking
an equal share of valued resources gain greater access to and control over
those resources”
• This is a useful concept because it focuses on the community as well as
the individual; a critical element of holistic empowerment and successful
socialization. Partnerships with local community groups to provide
mentoring would be a useful tool that might assist with socialization.
Basic living skills would be taught in a family type atmosphere that would
benefit both parent and child.

33. Schematic Framework of
Constrained Choice
SOCIAL POLICY
COMMUNITY ACTIONS
WORK
&
FAMILY
BIOLOGICAL PROCESSES
(e.g., Stress Responses)
HEALTH OUTCOMES
MORBIDITY
MORTALITY
INDIVIDUAL CHOICES
(e.g., Health Behaviors)

34. Decisions and Actions by
Families, Communities and
Governments Can:
• differentially affect men’s and women’s
choices and opportunities
• impact stress levels and exposure to
risks
• create incentives and disincentives for
engaging in health behaviors

35. Links Between Choice, Constraints,
and Cumulative Impact on Health
Broader social context and individual
“choice”
Jobs and Careers
• Marriage, Family, Children
• Neighborhood and Housing
• Amount and Use of Income
• Intergenerational Support

36. Constrained Choice and Rational
Actions
• People construct choices from priorities
and values (perception of options)
• Constrained choices shaped by
context(s) and meanings
• Go beyond economic and psychological
models of rational action
• Rational people make choices that don’t
maximize their health

37. Why Gender and Constrained
Choice Matter
• Gender differences in health are distinct
from racial and SES disparities
• Knowledge gaps hamper intervention
• Need health consciousness in decision
making at each level from individual to all
policy realms

38. Summary of Argument
• Biology interacts with social environment
• Social factors pattern the health trajectory
• Constrained choice shapes opportunity to
pursue health
• Need cross-disciplinary collaboration to
advance health of both men and women

39. New Approach
• Patient Centered approach
• Patient Navigation
• Housing
• Socialization

40. Abstract
The purpose of this paper is to describe a unique and innovative program
that uses an encounter with the justice system to offer a health care plan for
a subset of people going through drug court. With the application of social
theory to clinical practice, an intervention in the form of patient navigation is
developed in order to meet the needs of these clients. The paper offers a
description of the program and evaluation tools that may be used for
standardization and subsequent replication of this patient navigation model
to improve negative birth outcomes. Constraints on choice may be used to
explain the process of health care decision-making for this subset of people
going through a court mandated drug program. Considering the effects of
constrained choice as documented by Bird and Rieker (2008), a model
program was developed providing evidence of an increase in program
compliance for drug court clients and a reduction in the negative health
outcomes for this group of at-risk people. Patient navigation within the
framework of the constrained choice model offers a cost effective means of
improving health care outcomes for vulnerable populations.

41. Future
• Grant is currently being written in conjunction
with a social recovery piece
• Plan is to implement this in the Brooklyn Drug
Court in Brooklyn, NY
• Researchers from Bentley University,
Fordham, NYU, BU, and NDRI are participating

42. New Program to Implement
The broad goal is to manualize an innovative program for substance-abusing parents
with a holistic model aimed toward establishing healthy families. We integrate two
pilot tested programs used in drug court settings for substance-abusing adults.
The specific aim is:
To integrate a health intervention with a social capital model for court-involved
women of child-bearing age and men and women who are parenting children under
five with the goal to:
a) reduce negative birth outcomes
b) increase family education with a focus on early childhood development
c) reduce recidivism
d) reduce relapse rates
e) increase social capital networks
f) prevent infectious diseases associated with drug use, (HIV/AIDS/HCV)

43. Review of Program
• PIC tool
• Pre and post testing
• Daily activities
• Clients

44. PIC tool
• PreConception/Interconception Health
• We believe that all people deserve quality medical care. We
are giving this form to you today to provide you with
information about factors that can influence your health,
and possibly influence future pregnancies. About half of the
poor outcomes of pregnancy are determined by risk factors
that may be correctable before pregnancy. This checklist is a
way to help identify and thereby minimize those risks. This
form is meant to provide you with talking points to be
discussed with your medical provider. We are happy to go
over the definition of terms however we cannot give
medical advice. If you wish, we can assist you in scheduling a
medical appointment.

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