A MULTI-INSTITUTIONAL APPROACH TO IMPROVING MATERNAL & FETAL HEALTH Christie Webster, RNEC, OSFHT Dr. Hazel Lynn, MD, GBHU Dr. May Elhajj, MD, GBHS
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CFPC Conflict of Interest 2
Presenter Disclosure Presenter: Christie Webster Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None
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EXECUTIVE TRAINING FOR RESEARCH APPLICATION (EXTRA) 3
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Program offered by Canadian Foundation for Healthcare Improvement Vision: To build leaders in utilizing evidence to guide policy development & decision making in healthcare 14 month fellowship: team based Intervention project • • •
To engage team in a change strategy To utilize research based evidence To focus on a specific issue
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The Starting Point: Optimizing Maternal Fetal Health Optimal Weight Gain in Pregnancy
Planned Pregnancy
Eliminate Antenatal Smoking
Early Intervention with Postpartum Depression
Anecdote 5
Proportion of women who smoked cigarettes during pregnancy, by Public Health Unit, South West Region, 2008
Data source: Better Outcomes Registry and Network (BORN) Ontario 2008
Rates of smoking during pregnancy increased with decreasing maternal age – 44.8% of mothers under the age of 20 smoked during pregnancy, South West Region of Ontario BORN, 2008
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Context: Smoking Cessation 7
Services a population of 160,000; mandated to address the issue of smoking cessation related to population health with $350,000 of budget provided by smoke free Ontario program
Includes 6 hospitals that provide acute health care to Grey Bruce area. Owen Sound hospital is the only site that provides obstetrical care. Smoking cessation identified as a priority in strategic plan
Services 32,000 patients; trained clinical pharmacist & RN in smoking cessation counseling. Participating in Smoking Treatment for Ontario patients (STOP) program
Critical Summary of Evidence 8
ACOG and SOGC strongly endorse obstetricians being involved in smoking cessation programs Economic evaluations of smoking cessation and relapse prevention programs for pregnant women: a systematic review. Ruger, et al. Value Health. 2008 MarApr;11(2):180-90. For every dollar invested in smoking cessation programs, $3 are saved in downstream health-related costs.
Interventions for promoting smoking cessation during pregnancy. Lumley J. et al. Cochrane Database of Systematic Reviews, 3, 2009. Positive impact as far as pregnancy and fetus - less risk of complications
Neonatal care for infants born to smoking mothers: extra $700. Adams et al: Health Econ 2002
Critical Summary of Evidence – cont’d 9
EMRs-potentially valuable component to support smoking cessation Boyle R, Solberg L, Fiore M. Cochrane Database System Rev. 2011 Dec 7;(12):CD008743.
An office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral has been proved to increase quit rates. Obstet Gynecol. 2010 Nov;116(5):1241-4
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Change Management Process: The Constellation Model (Surman, T&M, 2008)
Need & Opportunity
Constellations: Self organizing action teams
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Extra team: Vision & Plan
Enabling Factors 12
Foundational agreement-EXTRA program No cost (our time) Collaborative partnerships Shared vision Feedback loops (stats, PHC providers, HCPs) Simple tools applied in practice EMR
Smoking status reminder EMR message for smoking cessation counseling Highlighted section in antenatal record#1
Smoking history is highlighted – if “yes” –refer for smoking cessation counseling
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Barriers 14
Communication challenges Large geographic area of Grey Bruce Multiple HCPs with varying levels of administrative support HCPs who lack skill in with dealing with a younger population High rate of “No Show/No Response” to smoking cessation counseling
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Results: Provider Initiated Referrals to Smoking Cessation Counseling TIME FRAME
IDENTIFIED # PROVIDER ANTENATAL INITIATED SMOKERS ON EMR REFERRALS
2010
0
2011
2
# NO SHOW &/OR NO RESPONSE
Jan - Aug 2012 **
30
Sept 2012 – Jan 2013
43
Feb – March 2013
6
1 (16.7%)
April – Dec 2013
28
14 (50%)
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Jan – April 2014
29
13 (44.8%)
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**Pre EXTRA IP
2 (6.7%) 16 (37.2%)
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Organizational Impact 16
Increased uptake of an available resource within an organization (smoking cessation counseling) Heightened awareness of the problem
Momentum for other organizations – role model Collaborative partnerships—beyond the project
Workshop “A Woman-Centered Approach to Tobacco Use & Pregnancy”-June 2013 (GBHU)
Breaking down the silos
Focus on a Modifiable risk factor – smoking cessation Reduce duplication of work between institutions Health Links—identification of factors that make pregnancy more expensive…reduce risk!
Smoking During Pregnancy 17 30
25
20
Percent
17.2 15
10.7 10
5
0
2006
2007
2008
2009 Year GBHU
Data Source: BORN Ontario, 2006–2012
Ontario
2010
2011
2012
Sustainability 18
Feedback to MDs, HCPs (referral rates)- accountability No structural reorganization; no redesigning patterns of delivery of care Patient focused - developed around the woman’s preconception/pregnancy journey
Next Steps 19
Partnership with Keystone Child, Youth & Family Services, host to Healthy Beginnings (CPNC) sessions for teenage pregnant families
Fall 2014 “lunch & learn” joint pilot project by OSFHT clinical pharmacist to
address stress mgmt & smoking cessation with interested clients (with or without partners); captive audience with food, transportation provided
3 sessions/year planned
Smoking cessation “swag” donated by GBHU
Host site application submitted to RNAO
Best Practice Champions for Smoke-Free Pregnancies Workshop
If accepted, to be offered to OSFHT and community partners
Electronic pre/postnatal resource document-developing (OSFHT)
Plan to educate HCPs on this resource
Questions? 20