Centering Pregnancy Celina Cunanan, CNM, MSN UH System Chief for Nurse-Midwifery Alison Tomazic Centering & Midwifery Program Manager Better Health Partnership Learning Collaborative April 13, 2018
No financial or non-financial conflicts of interests relevant to this presentation.
Learning Objectives: 1. To understand the concept and components of the Centering Pregnancy model of care 2. To review the impact of Centering Pregnancy on infant mortality and quality metrics 3. To discuss the local efforts to expand Centering Pregnancy
Infant Mortality
Infant Mortality is considered the hallmark of the overall health of a city, state or nation # deaths after live birth prior to one year of life per 1000 live births Healthy People 2020 Infant Mortality Rate Goal: 6.0 per 1,000 live births
Infant Mortality: United States, 2010
Infant Mortality Data 2007-2016 7
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CCBH Preliminary Infant Mortality Data 2017 YEAR Total Births Total Deaths Black IMR White IMR Overall IMR Black-to- White Disparity Preterm Birth Rate 2016* 14,747 128 14.9 4.8 8.7 6.1 12.1% 2017+ 14,548 116 15.6 2.5 7.9 6.1 12.2% *Official audited data from ODH for Cuyahoga County 2016 +CCBH unaudited data as of March 12, 2018--final statistics by mid-2018 9
March of Dimes 2017 Preterm Birth Report Card Cleveland 14.9% 9.8% 10.4% 12.1% Cuyahoga Ohio: Grade D Black women are 46% more likely to have a PTB vs white women Cuyahoga County: Grade F Cleveland has the worst rate of preterm birth out of 100 cities nationwide 10
What is Centering? Centering Pregnancy (CP) is an outcome-driven, cost-effective, patient-centered, innovative model of group care based on three components: 1. Health Assessment 2. Interactive Learning 3. Community Support
What is Centering?
Why Centering? Centering Pregnancy proven to: Triage visits Preterm birth rate (PTB) (<37 wks) Magnified for African-American women Low birth weight babies (LBW) (<2500g) Postpartum depression rates Breastfeeding rates Visit compliance Patient satisfaction Patient knowledge & readiness for birth
Other Advantages provider satisfaction patient revenue patient empowerment & ownership Builds community support Provides ongoing benefit to health across lifespan & to other disciplines (diabetes) Innovative models of care can help to address health care provider shortages CP is recommended by the Ohio Collaborative to Prevent Infant Mortality (OCPIM) & First Year Cleveland (FYC) as a key intervention to prevent preterm birth
Ickovics et al. (2007) Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics and Gynecology, 110(2), part 1: 330-39 To determine whether group prenatal care improves pregnancy outcomes, psychosocial function, & patient satisfaction; and to examine potential cost differences Multisite Randomized Controlled Trial Two University-affiliated hospital clinics (Yale, Emory) n=1047 (group=653 vs traditional=394) 80% African-American Mean age=20.4
Ickovics et al. (2007) Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics and Gynecology, 110(2), part 1: 330-39 Group care resulted in: 33% reduction in preterm birth (9.8% vs 13.8%) 41% reduction for AA women (10% vs 15.8%) Less likely to have inadequate prenatal care (26.6% vs 33%, p<.01) Better prenatal knowledge & readiness for labor & delivery (each p<.001) Greater satisfaction with care (p<.001) Increased breastfeeding initiation (66% vs 55%, p<.001) No added cost No difference in birth weight
How does Centering decrease PTB?
Maternal stress increases risk for PTB
Extreme Stress: Systemic Racism
Centering decreases maternal stress & builds community
Centering Pregnancy: University Hospitals
UH Centering Pregnancy Birthed by the Midwifery Division in 2010 Over $600K in grant funding + $670K ODM Sites: UH Rainbow/MacDonald (new Center July 2018) UH Ahuja (evening) UH Portage UH St. John Medical Center Fall 2018 Group model care: Centering Pregnancy Centering Parenting w/family Medicine Diabetes Boot Camp Group Diabetic Care Menopause Group Education Mom Power 24
UH Centering Pregnancy Innovations Innovations: 25
UH Centering Pregnancy Baby Box launch Nov 2016
Quality Outcomes: University Hospitals YEAR PTS ENROLLED PRETERM BIRTH (PTB) LOW BIRTH WEIGHT (LBW) BREASTFEEDING @ DISCHARGE C/S RATE TOTAL BIRTHS 2010 196 8% 8% 70% --- 125 2011 264 9.5% 5% 72% 17% 199 2012 176 13.6% 13.6% 71% 14% 169 2013 214 7% 14% 74% 16% 146 2014 227 6% 7% 85% 16% 171 2015 330 8% 9% 86% 13% 170 2016 206 5% 5% 85% 26% 164 2017 282 3.75% 4.3% 80% 22% 160 TOTALS 1895 7.61% 8.24% 78% 18% 1304 27
UH Centering Parenting
UH Centering Parenting May 2012-Dec 2017 Total enrollment=265 Program completion (thru 18 mos)= 197 Attendance Vaccine Compliance 2 mos 83% 100% 55% 4 mos 85% 100% 40% 6 mos 85% 100% 27% 12 mos 75% 96% 10% Breastfeeding Rate
UH Rainbow Center for Women & Children-July 2018 2 Centering rooms 2200 sq feet of group space Ability to run up to 6 groups/day
Lean Health Care Practitioner Certification: Centering Pregnancy Optimization Sept 2017 Tenisha Gaines Centering Program Director Project Lead Celina Cunanan, MSN, CNM UH System Chief for Nurse- Midwifery Ann Konkoly, MSN, CNM Medical Director, Women s Health Center Jessica Switzer Intern, Department of Operational Effectiveness 31
Recognize Define Measure Analyze Improve Control Realize Lean Certification: CP Value Stream Mapping Current Future 32
CP Billing Opportunities Bill for correct level of service Level 5 E/M for 10 visits Current Medicaid Reimbursement S/H modifier codes (6 code types) o Additional billed = $396/patient o Additional paid = $130/patient Goal: Enroll 500 patients in 2018 Additional billings = $198,000 Additional payments = $ 65,000 Opportunities Revenue Current state 6 patients/session $ 130.00 Future state 8 patients/session $ 248.00 Future state 8 patients/session with optimized billing $ 496.00 Future state 8 patients/session with optimized billing annually $ 83,328.00 33 Copyright 2016-2017 by KAVON International, Inc. & JMP Consulting, All Rights Reserved.
UH future Centering models OB Residency Continuity Clinic 2018 Mom Power incorporation 2018 Centering Parenting expansion 2018 Expansion to High Risk OB Populations Group diabetic care Obesity Preterm Birth Fetal Care Center patients Family Planning Family Medicine (FNP) HTN, Diabetes, Obesity UH Community Hospitals: SJMC, Elyria, Geauga, Parma, Portage
UH Named CHI Regional Leadership Partner in Midwest 35
FIRST YEAR CLEVELAND Centering Coalition
FYC SOLUTION: CREATE A DATA-INFORMED COMMUNITY COLLABORATIVE Organizational Description 13-Cuyahoga County civic leaders established First Year Cleveland in December 2015 FYC Advisory Council includes over 300 community representatives from more than 70 organizations FYC is a collaborative, grassroots effort with a bottom-up approach FYC draws on the experience and wisdom of our community Parents and grandparents Neighbors Frontline caregivers Leaders from health systems, civic groups, volunteer organizations, and faith-based community 37
FYC SOLUTION: CREATE A DATA-INFORMED COMMUNITY COLLABORATIVE Structure Case Western Reserve University School of Medicine serves as First Year Cleveland's fiscal agentand provides in-kind support for executive staff leadership and operations, including space. 2016-2018 funders include: Ohio Department of Medicaid Ohio Department of Health including Cleveland-Cuyahoga County Ohio Equity Institute Cuyahoga County, County Executive Armond Budish and Cuyahoga County Council City of Cleveland, Cleveland Mayor Frank G. Jackson and Cleveland City Council 38
FYC STRATEGIC PLAN: VISION + MISSION Our Vision Every baby born in Cuyahoga County will celebrate a first birthday Our Mission Tomobilize the community through partnerships and a unified strategy to reduce infant deaths including racial disparities 39
FYC STRATEGIC PLAN: 3 PRIORITIES THROUGH 2020 1. Reduce Racial Disparities 2. Address Extreme Prematurity 3. Eliminate Preventable Sleep-related Infant Deaths 40
FYC MOBILIZATION STRATEGY 2018-2020 41
FYC Centering Coalition-est Nov 2016 Co-Chairs: Alison Tomazic (NFP) & Celina Cunanan, CNM, MSN (UH) Purpose: Support network for CP coordinators and providers in Cuyahoga County Share best practices, discuss challenges, brainstorm ideas Provide local CHI facilitation training for Coalition members Present a unified message about Centering across the county Centering newsletter for service agencies and providers MomsFirst, WIC, Bright Beginnings, etc. County wide data collection with Cuyahoga County Board of Health
FYC Centering Coalition Members FQHCs: Neighborhood Family Practice (NFP) Northeast Ohio Neighborhood Health Services (NEON) Care Alliance Partners: FYC Executive Director Ohio Equity Institute Cuyahoga County Board of Health Hospitals: University Hospitals Cleveland Clinic Metro Health
FYC ODM Funding: Rounds 1 & 2 (1/1/17-12/31/18) $1.5 M over 2 yrto fund Centering expansion to FQHCs: NFP Expansion to Puritas-June 2017 Care Alliance Initiation in Central Neighborhood- June 2017 NEON Restarted at Hough site-may 2017
FYC ODM Funding: Round 3 (1/1/18-6/30/19) $1.4 M for Centering Pregnancy in Cuyahoga County UH, CCF, Metro NFP Enrollment goals: Q4 2018: 500-1000 Q4 2019: 2000 45
2017 Preliminary Coalition Outcomes All 6 programs reporting: Preterm Birth Rate=4.9% Low Birth Weight=4.5% Breastfeeding at Discharge Rate=69.3% African-American=77%
CALL FOR ACTION Talk to clients about their risks Talk to clients about the benefits of Centering Refer clients to any of the 6 Centering Coalition sites Support efforts to expand Centering programs in your areas Support higher reimbursement for Medicaid and commercial insurances for Centering
Thank You! 48