Centering Pregnancy

Celina Cunanan, CNM, MSN Alison Tomazic

UH System Chief for Nurse-Midwifery 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 overallhealth of a city, state or nation

# deaths after live birth prior to one year of lifeper 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

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CCBH Preliminary Infant Mortality Data 2017

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YEAR Total Births

TotalDeaths

Black IMR

White IMR

OverallIMR

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

March of Dimes 2017 Preterm Birth Report Card

Ohio:

� Grade D

� Black women are 46% more likely to have a PTB vs white women

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9.8% 10.4%

14.9%

12.1%Cuyahoga

Cleveland

Cuyahoga County:

� Grade F

� Cleveland has the worst rate of preterm birth out of 100 cities nationwide

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) (

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

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

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UH Centering Pregnancy Innovations

• Innovations:

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UH Centering Pregnancy Baby Box launch Nov 2016

Quality Outcomes: University Hospitals

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YEAR PTSENROLLED

PRETERMBIRTH (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

UH Centering Parenting

UH Centering Parenting May 2012-Dec 2017

• Total enrollment=265

• Program completion (thru 18 mos)= 197

Attendance Vaccine Compliance

BreastfeedingRate

2 mos 83% 100% 55%

4 mos 85% 100% 40%

6 mos 85% 100% 27%

12 mos 75% 96% 10%

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

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Lean Certification: CP Value Stream Mapping

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Recognize Define Measure Analyze Improve Control Realize

Current

Future

CP Billing Opportunities

33© Copyright 2016-2017 by KAVON International, Inc. & JMP Consulting, All Rights Reserved.

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/patiento 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$

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

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FIRST YEAR CLEVELAND

Centering Coalition

FYC SOLUTION: CREATE A DATA-INFORMED COMMUNITY COLLABORATIVE

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• 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

Organizational Description

FYC SOLUTION: CREATE A DATA-INFORMED COMMUNITY COLLABORATIVE

Structure

Case Western Reserve University School of Medicine serves as First Year Cleveland's

fiscal agent and 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

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FYC STRATEGIC PLAN: VISION + MISSION

Our VisionEvery baby born in Cuyahoga County will celebrate a first birthday

Our MissionTo mobilize the community through partnerships and a unified

strategy to reduce infant deaths including racial disparities

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FYC STRATEGIC PLAN: 3 PRIORITIES THROUGH 2020

1. Reduce Racial Disparities

2. Address Extreme Prematurity

3. Eliminate Preventable Sleep-related Infant Deaths

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FYC MOBILIZATION STRATEGY 2018-2020

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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 MembersFQHCs:

• 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 yr to 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

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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!

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