Transcript Slide 1

Transforming Maternity
Care
Blueprint for Action:
Steps Toward a High Quality, High
Value Maternity Care System
Opportunities for Quality
Collaboratives
NJHA, June 22, 2010
R. Rima Jolivet, CNM, MSN, MPH
Transforming Maternity Care Project Director
Associate Director of Programs
Childbirth Connection
www.childbirthconnection.org
Childbirth Connection
Mission
To improve the quality
of maternity care
through research,
education, advocacy,
and policy.
www.childbirthconnection.org
US Maternity Care Facts…
• 4.3 million births in 2007, the most ever recorded
• Maternal-newborn care is the most common reason for
hospitalization, and accounts for 25% of all discharges
• 6 out of 10 most common hospital procedures are
maternity-related
• The most common operating room procedure is cesarean
section
• The national cesarean rate is 32% (another record high)
• Cesarean rates vary by payer:
– private = 33.7%, Medicaid = 29.8%, uninsured = 25.4%
References at http://www.childbirthconnection.org/article.asp?ck=10621
www.childbirthconnection.org
…and Figures
• Combined maternal/newborn facility charges were $86
billion in 2006
• In 2006, 42% of all births billed to Medicaid
• In 2007, 53% of all hospital discharges billed to
Medicaid were maternity-related
• Similarly, half of all births billed to private insurers
• 35% of all hospital discharges billed to private insurers
were maternity-related
References at http://www.childbirthconnection.org/article.asp?ck=10621
www.childbirthconnection.org
New Jersey DoH data
• In NJ, the rate of cesarean with no trial of labor has risen
significantly since the late 90’s while the rate of vaginal
birth has declined steadily
• From 1999-2004, the annual growth in cesarean rates was
greater than 5% for primary NTSV (standard), primary
multip standard, primary singleton preterm, and repeat
standard
• The nulliparous cesarean rate following induction rose
6%/yr from 1997-2008 for a cumulative increase of 102%,
and the nulliparous CS rate with no trial of labor rose 14%
for a cumulative increase of 368% over the same period
Denk, 2009
www.childbirthconnection.org
Much of the care women receive is
not consistent with the best evidence
The 2008 Milbank report reveals:
• A pattern of wide practice variation, unwarranted by
health status or women’s preferences
• Overuse of many practices that entail harm and waste
for mothers, babies, and the system at large
• Other effective, high-value practices that are
systematically underused
Sakala & Corry, 2008 (available at: www.childbirthconnection.org)
www.childbirthconnection.org
www.childbirthconnection.org
The full reports are available at:
www.childbirthconnection.org
and
www.whijournal.com
Transforming Maternity Care
2020 Vision for a High Quality, High Value
Maternity Care System
• Fundamental values and principles that apply across the
whole continuum of maternity care
• Goals for each phase and for providers and settings for
maternity care
• Attributes of the larger system that can reliably provide
high quality, high value care to all childbearing women,
their newborns and families
www.childbirthconnection.org
Blueprint for Action:
Steps Toward a High Quality, High Value
Maternity Care System
• Five stakeholder workgroups developed
detailed sector-specific reports
• Actionable strategies in 11 critical focus areas
• Synthesized into a comprehensive Blueprint for
Action by the Symposium Steering Committee
• Full stakeholder reports are published online at:
www.childbirthconnection.org/workgroups
www.childbirthconnection.org
Blueprint for Action:
Steps Toward a High Quality, High Value
Maternity Care System
11 Critical Focus Areas:
• Performance measurement and leveraging of
results
• Payment reform to align incentives with quality
• Disparities in access and outcomes of maternity
care
• Improved functioning of the liability system
www.childbirthconnection.org
Blueprint for Action:
Steps Toward a High Quality, High Value
Maternity Care System
11 Critical Focus Areas:
• Scope of covered services for maternity care
• Coordination of maternity care across time, settings, and
disciplines
• Clinical controversies (home birth, VBAC, vaginal breech and
twin birth, elective induction, and maternal demand cesarean
section)
• Decision making and consumer choice
• Scope, content, and availability of health professions education
• Workforce composition and distribution
• Development and use of health information technology (IT)
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
Blueprint for Action:
Steps Toward a High Quality, High Value Maternity
Care System
‘‘Who needs to do what, to, for, and with whom to
improve the quality of maternity care over
the next five years?’’
www.childbirthconnection.org
Blueprint for Action:
Selected Recommendations and Strategies
Performance Measurement and Leveraging of
Results
• Develop, test, and submit to NQF measures to address crucial topical
gaps, including informed decision making, VBAC, comfort measures and
pain relief, postpartum hospital practices that impact attachment and
breastfeeding, and persistent physical and emotional problems that arise
in the postpartum period.
• Identify a core subset of national consensus measures for rapid reporting.
Begin implementation with pilots to identify barriers that may result due to
administrative variation across and within systems, and scale up.
• Develop state or regional quality collaboratives that bring hospitals,
clinicians, consumers, and payors together to test the impact of
performance measures on P4P, audit and feedback, QI indicators.
www.childbirthconnection.org
Blueprint for Action:
Selected Recommendations and Strategies
Payment Reform to Align Incentives with
Quality
• Build a better bundled payment system for maternity care, adapting
“From Volume to Value” model to maternity care (Miller, 2008)
• Pilot the model through regional demonstration projects involving all
payors and providers to decide on indicators and targets, to design
mechanisms for cost- and revenue-sharing and incentives for valuebased care coordination, and to test the outcomes of alternative
payment models based on these determinants
• Encourage state Medicaid programs to use policy levers to
coordinate implementation
www.childbirthconnection.org
Blueprint for Action:
Selected Recommendations and Strategies
Disparities in Access and Outcomes of Maternity
Care
•
Form quality collaboratives and community-based partnerships to
evaluate and implement programs to close disparities in maternity
care outcomes.
•
Carry out comparative effectiveness research and apply disparitiessensitive criteria from the National Voluntary Consensus Standards
for Ambulatory Care: part 2 (NQF, 2009) when collecting quality
improvement data
•
Test effect on outcomes and cost of preventive programs such as
Centering Pregnancy, language translation, care coordination, doulas,
nurse home visitation, and comprehensive breastfeeding promotion
www.childbirthconnection.org
Blueprint for Action:
Selected Recommendations and Strategies
Improved Functioning of the Liability System
• Widely adopt system-oriented patient safety and quality improvement
programs, and measure and report experiences with malpractice
claims and payments.
• Evaluate the impact on reduction of adverse events and liability
experiences, and satisfaction of women and providers, of: the laborist
model, various team models and mechanisms for community
coordination, regular team training and emergency drills, evidencebased checklists, and policies that provide better rest for maternity
care providers
• Pilot, evaluate, and share results of ‘‘enterprise liability’’ programs
that relocate responsibility from individuals to systems.
www.childbirthconnection.org
Blueprint for Action:
Selected Recommendations and Strategies
Coordination of Maternity Care Across Time,
Settings, and Disciplines
• Develop local and regional QI initiatives designed to improve
coordination at the community level
• Establish mechanisms for 24-hour open access to MFM specialists by
community providers for consultation, co-management , or referral
• Convene an inclusive, interdisciplinary team of FP, OB, MFM and
midwives, and use actual community patient safety data on near misses
and reportable adverse events to develop community-specific
consensus risk criteria for level of care including settings and providers,
replicating Intermountain’s model
• Conduct multi-disciplinary periodic review of all transfers and
complications from community to higher levels of care to engage in joint
problem solving
www.childbirthconnection.org
The potential
to improve
maternity care
is within our
reach, but
none of us can
do it alone.
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
The TMC Partnership:
www.childbirthconnection.org/Partnership
• Outreach and dissemination to decision makers, including
policy makers and legislators
• Joint Blueprint implementation projects of a significant
scope, undertaken with organizations that have the
capacity and resources to accelerate health system change
• The TMC Action Community: A forum for community-level
partners to show support for the Vision and Blueprint, and
get ideas and resources for ways to independently engage
in this work within their own communities and practice
settings
www.childbirthconnection.org
Thank You!
R. Rima Jolivet, CNM,
MSN, MPH
Transforming Maternity
Care Project Director
Associate Director of
Programs
Childbirth Connection
jolivet@
childbirthconnection.org
www.childbirthconnection.org