Caring for mothers and newborns after an uncomplicated delivery: towards integrated postnatal care NADIA BENAHMED, CARL DEVOS, LORENA SAN MIGUEL, LIESBETH VANKELST, EMELIEN LAUWERIER, MARGUERITE VERSCHUEREN, CAROLINE OBYN, IRM VINCK, DOMINIQUE PAULUS, WENDY CHRISTIAENS RvB, 21/10/2014 D. Paulus Background I 121 000 deliveries per year in 99 maternity units. Average length of stay: 4.1 days (2013) Decreasing trend, but still among the longest in OECD countries Hungary Slovak Czech Republic France Belgium Austria Greece Luxembourg Poland Slovenia Switzerland Italy Finland Germany Norway OECD32 Israel Chile Australia Denmark Portugal Korea Spain Sweden Ireland Netherlands United States Iceland New Zealand Canada United Kingdom Turkey Mexico 4,5 4,2 4,1 4,0 4,0 4,0 3,9 3,9 3,9 3,4 3,1 3,1 3,1 3,0 2,9 2,8 2,7 2,7 2,7 2,6 2,5 2,3 2,0 2,0 2,0 1,8 1,8 1,7 1,6 1,5 1,3 5,2 5,2 0 2 4 6 Days Source: OECD, 2013, Health at a Glance 2013 2 Background II Variability among hospitals regarding the provision of structured postnatal follow-up at home 1
Requested by RIZIV/INAMI FPS Health, Food chainsafetyand environment Center for postnatal expertise De Bakermat A gynaecologist 4 Objectives & methods RQ 1: Organisation, use and financing of postnatal care? RQ 2: Drivers and barriers? Analysis of administrative datasets(ima-aim database and the TCT coupled data) Focus group interviews with mothers and health care practitioners RQ 3: Comparison with SE, UK and NL? RQ 4: Consequences for quality of care? RQ 5: Financial consequences? Narrative literature review Narrative literature review Cost-estimations by means of theoretical scenarios. 5 In sum - What are the weaknesses of the current organisation of postnatal care? - Earlier postnatal discharge with follow-up at home: what is needed? 2
Qualitative research 10 focus groups (56 participants) 2 with mothers (long stay) 2 with mothers (short stay) 2 with obstetricians 2 with midwives 1 with general practitioners 1 with representatives of maternity home care assistants Purposive sampling, participants from all over Belgium Inform and support parents READMISSIONS OF NEWBORNS - MOTHERS Appropriate workforce Financial incentives Processes in support of quality of care Knowledge management 8 9 3
Plan and coordinate postnatal care Recommendation1: Organisationseamless postnatal care with follow-up at home interprofessionalcooperation coordinationbetween secondary and primary levels of care monitoring qualityof postnatal care Recommendation2: Multidisciplinary perinatal care network Actionpoints 1. Shared web-based maternityrecord 2. Registrationof health service use and epidemiology 3. Appoint a perinatalcare coordinatorfor each birth 4. NationalPerinatalCare Platform 10 11 Antenatal preparation resulting in an individual postnatal care plan Recommendation 3: Antenatal care needs to be integrated with postnatal care by a perinatalcare coordinator Action point: 1. Antenatal preparation should result in a postnatal care plan that could be added to the shared postnatal care module of the electronic maternity record. 12 4
13 Provide seamless postnatal care, less at hospital, more at home Recommendation 4: Hospital up until 72 hours after birth or less Follow-up at home during the first week of life and ideally up until day 10organised before discharge according to the individual needs of mother and newborn. Action points: 1. Organise postnatal follow-up (a guard duty service, telephone support, workforce). 2. Multidisciplinary clinical pathway (continuityof care hospital -home setting, dischargeprocess) 3. Evidence-based clinical guideline 4. Appropriate neonatal screenings 14 READMISSIONS OF NEWBORNS - MOTHERS 15 5
Develop and implement uniform readmission procedures for newborns and their mothers Recommendation 5: Develop a standard readmission protocol for newborns and their mothers. Register all (re)admitted newborns and monitor newborn (re)admissions in a uniform way allowing for qualityassessment and benchmarking. 16 READMISSIONS OF NEWBORNS - MOTHERS Appropriate workforce Processes in support of quality of care 17 Processes in support of quality of postnatal care Recommendation 6: Define quality criteria for follow-up at home and for postnatal inpatient care Actionpoint: Supplement or revise curriculum of training programmes 18 6
Inform and support parents READMISSIONS OF NEWBORNS - MOTHERS Appropriate workforce Processes in support of quality of care 19 Support parents in their (new) caring role Recommendation 7: Support mothers and fathers in their (new) parenting role Action points: 1. Professionalise maternity home assistance and integrate them in a coherent framework of multidisciplinary postnatal follow-up at home 2. Stimulate peer support and parental education 20 Inform and support parents READMISSIONS OF NEWBORNS - MOTHERS Appropriate workforce Financial incentives Processes in support of quality of care 21 7
Payment systems to facilitate integrated and seamless postnatal care and in support of shorter hospital stays Recommendation 8: Let the current hospital payment system evolve to support shorter stays complemented with follow-up at home. Action points: Set up pilot projects Consider recalibration of midwives remuneration 22 Inform and support parents READMISSIONS OF NEWBORNS - MOTHERS Appropriate workforce Financial incentives Processes in support of quality of care 23 Special attention for equal access to postnatal care Recommendation 9: Prevent them from dropping out of perinatal care. National perinatal programme for vulnerable families. 24 8
Inform and support parents READMISSIONS OF NEWBORNS - MOTHERS Appropriate workforce Financial incentives Processes in support of quality of care Knowledge management 25 Need for scientific research Recommendation 10: Plan and monitor at the highest level the workforcerequirements and consider further research oncost-effectiveness of integrated and seamless postnatal care characterised by earlier discharge with follow-up at home. 26 To conclude Propositions are a cluster of interdependent solution elements Next steps: Special attention for vulnerable groups From recommendations to concrete actions 27 9
THANK YOU! 28 All recommendations in full version 29 Plan and coordinate postnatal care Recommendation 1: Prioritise the organisation of follow-up at home in order to provide integrated, hence seamless postnatal care. In order to be successful interprofessional cooperation, coordination between secondary and primary levels of care and monitoring quality of postnatal care need to be developed, supported and maintained. 30 10
Plan and coordinate postnatal care Recommendation 2: Develop and implement multidisciplinary perinatal care networks around each mother and newborn, that share a computer-based care plan and care coordination tool, based on the current global patient record (Globaal medisch dossier/dossiermedical Global) Action point 2.1: Prioritise the development and implementation of a shared web-based maternity record accessible for mothers and able to automatically generate input for administrativeand epidemiological registration institutions Action point 2.2: Integrate the registration of health service use and epidemiological data (ebirth) in the shared web-based maternity record. Facilitate the management and analysis of these data by enabling the linkage between newborns and their mother and by providing newborns a social security identification code (national number) immediately after birth Action point 2.3:appoint a perinatal care coordinator in each perinatal care network Action point 2.4:Bring together all the organisations involved in perinatal care in a National Perinatal Care Platform 31 Antenatal preparation resulting in an individual postnatal care plan Recommendation 3: Antenatal care needs to be integrated with postnatal care. Introduce postnatal preparation during antenatal consultations starting in early pregnancy. Let the preparation result in a postnatal care plan, integrated in the shared maternity record and guarded by the perinatal care coordinator. Action point 3.1: Antenatal preparation should result in a postnatal care plan that could be added to the shared postnatal care module of the electronic maternity record. 32 Provide seamless postnatal care, less at hospital, more at home Recommendation 4: After uncomplicated vaginal delivery, provide postnatal care in hospital up until 72 hours after birth or less, a seamless transfer from hospital to home by means of a clinical pathway and follow-up at home during the first week of life and ideally up untillday 10. The follow-up at home should be organised before discharge according to the individual needs of mother and newborn. Action point 4.1: organise postnatal follow-up at home by midwives (or GPs), including a guard duty service and telephone support, for all mothers who had an uncomplicated vaginal delivery and take this into account in the workforce planning of midwives. Action point 4.2.: develop and implement a multidisciplinary clinical pathway to ensure continuity of care between the hospital and the home setting and document the discharge process in the shared web-based maternity record 33 11
Provide seamless postnatal care, less at hospital, more at home Action point 4.3: Develop a evidence-based clinical guideline for postnatal care, including the required number and intensity of home visits relative to the number of days in hospital Action point 4.4: Make sure that every newborn receives the appropriate neonatal screenings, if not in hospital, at home. Make neonatal screenings the responsibility of the perinatal care coordinator and register them in the shared maternity record. 34 Develop and implement uniform readmission procedures for newborns and their mothers Recommendation 5 Develop a standard readmission protocol for newborns and their mothers. Register all (re)admitted newborns and monitor newborn (re)admissions in a uniform way allowing for quality assessment and benchmarking. 35 Processes in support of quality of postnatal care Recommendation 6: Define quality criteria for follow-up at home based on the clinical guideline for postnatal care and adapt the competences of midwives, GP s and maternity home assistants to their (new) role in the provision of postnatal care. Action point 6.1:Supplement or revise curricula of training programmes for midwives and physicians aligned with the quality criteria in general, and the coordinating role in particular. 36 12
Support parents in their (new) caring role Recommendation 7:Support mothers and fathers in their (new) parenting role by developing maternity home assistance and encourage parent groups to foster peer support. Action point 7.1:Professionalize maternity home assistance and integrate them in a coherent framework of multidisciplinary postnatal follow-up at home Action point 7.2:Consider structurally embedding parent groups to stimulate peer support and parental education. Consider CenteringParentingas a continuation of CenteringPregnancyas a good working model. 37 Payment systems to facilitate integrated and seamless postnatal care and in support of shorter hospital stays Recommendation 8:Let the current hospital payment system evolve by means of pilot projects to become more supportive of high-quality, integrated, multidisciplinary postnatal care. The remuneration system of the key care providers should be adapted in order to facilitate cooperation between health care professionals and support shorter stays complemented with follow-up at home. Action point 8.1:Set up pilot projects in which the implementation of integrated, multidisciplinary perinatal home care and payment mechanisms are tested. Action point 8.2:Consider recalibration of midwives remuneration to be congruent with their coordinating role in postnatal care, to support home visits up until day 10, to recognise the additional time needed for the first home visit and the time spent at telephone consultations. 38 Special attention for equal access to postnatal care Recommendation 9 Reflect on coordinated actions to support vulnerable families and prevent them from dropping out of perinatal care. Consider the development of a national perinatal programme for vulnerable families, with extra investment in the accessibility of antenatal care for vulnerable families, perinatal coaching, additional residential solutions, and the development of a hotline for care providers. 39 13
Need for scientific research Recommendation 10:Plan and monitor at the highest level the workforce requirements and consider further research on cost-effectiveness of integrated and seamless postnatal care characterised by earlier discharge with follow-up at home. 40 14