Using Centering Pregnancy to Teach Prenatal Care: Implementing Group Prenatal Care in a Family Medicine Residency Wendy Brooks Barr, MD, MPH, MSCE Sarah Miller, MD Yonit Lax Leila Hagshenas, MD Natasha Kelly, DO Julia Helstrom, DO & Marc Levin, MD Beth Israel Residency in Urban Family Medicine, New York, NY

CENTERING: a model for group health care CenteringParenting ™ CenteringPregnancy®

Objectives As a result of this session, the participant will: 1) Identify the educational advantages of the group model of care to teach prenatal care. 2) Identify the educational challenges of using a group model of care to teach prenatal care. 3) Develop strategies to maximize the educational advantages and minimize the disadvantages of the group model of care for residency prenatal care education in their own settings. 3) Develop strategies to maximize the educational advantages and minimize the disadvantages of the group model of care for residency prenatal care education in their own settings.

Overview of Centering Pregnancy

Dr. Donald Berwick, co-founder of the Institute for Health Care Improvement says, “ The health care system is broken and band-aids won’t work”

You are a pregnant mom... You are a pregnant mom... No waiting No waiting A community of friends A community of friends Relaxed time with your provider Relaxed time with your provider Opportunity to talk about pregnancy, birth, parenting..even set personal goals Opportunity to talk about pregnancy, birth, parenting..even set personal goals Time for lots of discussion Time for lots of discussion Fun at your visits Fun at your visits Imagine…

You are a provider... You are a provider... Having time to really listen to your moms Having time to really listen to your moms Getting help from the group with problem- solving Getting help from the group with problem- solving Needing to say things only once Needing to say things only once Working with really activated patients Working with really activated patients Finding work fun and energizing Finding work fun and energizing Imagine…

You are an administrator... You are an administrator... Better access for your patients Better access for your patients Freed-up exam rooms for paying procedures Freed-up exam rooms for paying procedures Happy providers/staff….less turnover Happy providers/staff….less turnover Great marketing program Great marketing program Better birth outcomes Better birth outcomes Predictable clinic time schedules Predictable clinic time schedules Imagine…

You are a learner... You are a learner... One-on-one precepting time focused on OB 4 hours per month One-on-one precepting time focused on OB 4 hours per month Learning from peers and pregnant women Learning from peers and pregnant women Learning in a relaxed environment Learning in a relaxed environment Imagine…

Why Groups?  Time to share joys and concerns  Build community  Creative problem- solving  Efficient way to share information  Better evidence-based outcomes

Groups provide… A vehicle for social change An opportunity to learn from each other Fun and interesting sharing

Centering Pregnancy Provides Better Obstetric Outcomes (SORT A) Reduce prematurity (OR 0.67 [ ], p=0.045) Reduce prematurity (OR 0.67 [ ], p=0.045) Improved patient knowledge (p<0.001) Improved patient knowledge (p<0.001) Enhanced patient satisfaction (p<0.001) Enhanced patient satisfaction (p<0.001) Higher breastfeeding initiation rates (OR 1.73 [1.28, 2.35], p=0.001) Higher breastfeeding initiation rates (OR 1.73 [1.28, 2.35], p=0.001) Ickovics JR, et.al. Group prenatal care and perinatal outcomes: a randomized control trial. Obstet Gynecol. 2007;110:330-9.

“In truth, I continue to be awed by the power of the group. We are having such a good time and have such laughs. I am learning that it doesn’t matter what we don’t talk about, because we are talking about what matters to the group.” - Claire Westdahl, CNM - Claire Westdahl, CNM

“I thought it was a really good idea and much better than individual session. Because I was the youngest one there and it is especially good for young people who can't decide to have older experienced people there.” Centering Patient at PFP

“ They made me feel like part of the family. I liked the personal aspect. They cared about you after the birth and how you were feeling and your entire family was doing with the new baby. I liked how all doctors cared, not just the delivery doctor.” Centering Patient at PFP

General Program Design Initial intake to system before entry into a group (individual visit(s) with team resident(s)) Initial intake to system before entry into a group (individual visit(s) with team resident(s)) History, physical assessment/lab work completed History, physical assessment/lab work completed Case reviewed as appropriate for group care Case reviewed as appropriate for group care Groups of women, same month/block EDD invited to group Groups of women, same month/block EDD invited to group Begin between weeks GA Begin between weeks GA Confidentiality agreement signed Confidentiality agreement signed Partners encouraged to attend Partners encouraged to attend

The Design... Four sessions every 4 weeks: Four sessions every 4 weeks: 16, 20, 24, 28 16, 20, 24, 28 Six sessions every 2 weeks: Six sessions every 2 weeks: 30, 32, 34, 36, 38, 40/PP 30, 32, 34, 36, 38, 40/PP - additional visits as needed - additional visits as needed for problems for problems - weekly visits during the last - weekly visits during the last month, if desired month, if desired

The Visit Self Assessment Self Assessment Individual Physical Assessment Individual Physical Assessment individual triage with provider individual triage with provider Education Education Support and Community Building Support and Community Building Closing the Visit Closing the Visit

Self Assessment Women do self- monitoring of: Current gest. age weight B/P Women document data in the chart (ACOG forms)

Self-Assessment Self-Assessment Weight Weight Blood pressure Blood pressure Gestational age Gestational age Urine, prn Urine, prn Charting/chart review Charting/chart review SAS Sheets/notebooks SAS Sheets/notebooks

SELF-ASSESSMENT SHEETS for CenteringPregnancy® (SELECTED)... Nutrition Nutrition Common Pregnancy Problems Common Pregnancy Problems Family Issues Family Issues Parenting Styles Parenting Styles Relaxation Measures Relaxation Measures Comfort Measures for Labor Comfort Measures for Labor

Individual Physical Assessment Individual Individual physical physical assessment done assessment done within group space within group space by a provider by a provider

Individual Physical Assessment Fundal Height Fetal Heart Tones Fetal Position Maternal / Fetal Well Being Appropriate Testing

Education 10 two-hour sessions facilitated by group leader, usually the health care provider 10 two-hour sessions facilitated by group leader, usually the health care provider Visits in circle Visits in circle Facilitated leadership Facilitated leadership Outside speakers Outside speakers

Education Comfort issues/stress reduction Comfort issues/stress reduction Exercise / relaxation Exercise / relaxation Nutrition and infant feeding Nutrition and infant feeding Birth preparation and recovery Birth preparation and recovery Sexuality/contraception... Sexuality/contraception...

Education Communication / self esteem Communication / self esteem Issues of abuse Issues of abuse Baby care/safety Baby care/safety Infant development Infant development Parenting Parenting

Support and Community Building Refreshments Refreshments Formal and Formal and informal sharing informal sharing Stability of group Stability of group Exchange of Exchange of names, telephone names, telephone numbers numbers Consistency of Consistency of leadership leadership

Closing the Visit Future date reminders Future date reminders Individual chart reviews - patient, resident, attending Individual chart reviews - patient, resident, attending Social time Social time Charting (EHR) Charting (EHR) After patients leave After patients leave Team reviews cases and determines if any outreach or follow-up is needed Team reviews cases and determines if any outreach or follow-up is needed

Making Centering Pregnancy “Routine Care” Expansion Phase

We want to do groups!

March of Dimes Chapter Community Grants Strong support for starting more Centering Pregnancy programs based on research that shows it prevents prematurity Strong support for starting more Centering Pregnancy programs based on research that shows it prevents prematurity Applied for $ in February 2007 for 2008 Grant cycle Applied for $ in February 2007 for 2008 Grant cycle Grant approved in Dec 2007 for $28,648 Grant approved in Dec 2007 for $28,648 Grant cycle: February 1, 2008 – February 2009 Grant cycle: February 1, 2008 – February 2009

How the Grant Helps Training staff Training staff Send more faculty to Centering training programs Send more faculty to Centering training programs Purchase facilitator guides to train residents on site Purchase facilitator guides to train residents on site Americorps Volunteer Americorps Volunteer Integration with IMPLICIT project Integration with IMPLICIT project Encourage organization matching to purchase needed equipment Encourage organization matching to purchase needed equipment Automatic BP cuff Automatic BP cuff Portable scale Portable scale Mats/Pillows Mats/Pillows Privacy screen Privacy screen

Switching from Pilot to Requirement Three faculty are trained and assigned to co-facilitate groups (faculty continuity within group) Three faculty are trained and assigned to co-facilitate groups (faculty continuity within group) 8 Groups a year (follows existing continuity block schedule) 8 Groups a year (follows existing continuity block schedule) Every resident co-facilitates a group for their continuity OB patients Every resident co-facilitates a group for their continuity OB patients 2 groups throughout their residency – R2, and R3 years 2 groups throughout their residency – R2, and R3 years Group session replaces an evening clinic Group session replaces an evening clinic Patient numbers count for both residents (RRC exemption) Patient numbers count for both residents (RRC exemption)

Administrative Challenges

Scheduling Evening clinic best to recruit patients into group (also most cost effective as it’s a shorter session) Evening clinic best to recruit patients into group (also most cost effective as it’s a shorter session) R1 resident work hour concerns (do not usually do an evening clinic) R1 resident work hour concerns (do not usually do an evening clinic) Coordination of schedules for attending, residents, and clinic Coordination of schedules for attending, residents, and clinic Need good prenatal coordinator! Need good prenatal coordinator!

Resident Continuity With Group Block Scheduling for resident deliveries Block Scheduling for resident deliveries 2 person resident prenatal teams 2 person resident prenatal teams How to deal with existing patients How to deal with existing patients Temporary transfer to prenatal team Temporary transfer to prenatal team Share care between PCP and prenatal team Share care between PCP and prenatal team

Educational Advantages

Curricular Model Annual talk on Centering Pregnancy concepts to residents Annual talk on Centering Pregnancy concepts to residents All residents facilitate 2 Centering Pregnancy groups in their residency All residents facilitate 2 Centering Pregnancy groups in their residency Each group facilitated by a trained attending, R3, and R2 resident (continuity residents) Each group facilitated by a trained attending, R3, and R2 resident (continuity residents) R3 resident acts as mentor to R2 residents and lead facilitator R3 resident acts as mentor to R2 residents and lead facilitator Facilitator guides are read and reviewed by residents as go through group Facilitator guides are read and reviewed by residents as go through group Residents participate in OB chart review sessions Residents participate in OB chart review sessions

Resident Advantages to Group “I had a great education experience...I was able to learn from my patients, other residents, and attendings. I was able to use my new found knowledge in my regular clinic session with those patient not in group. In addition, I bonded with patients and got to know them better than I would have in a regular session. If I were to practice OB care in the future, I would definitely do group visits.” R3 Family Medicine Resident

Resident Advantages to Group “I came into residency with almost no knowledge of prenatal care and a real fear of going anywhere near a woman in labor. Group prenatal visits were kind of a life-changing experience for me. It was so relaxed, such a different feeling from individual, 15-minute patient encounters where I had to keep running back to the precepting room. Before each group, I could prep with materials from the centering book, and if I was ever stumped by a patient's or partner's question, I had an attending and another resident right there to back me up. I never felt put on the spot, I really learned a lot from our patients, and now I actually feel comfortable doing prenatal care. and yes, I even like delivering babies.” R3 Family Medicine Resident

Evaluation

Impact on Prenatal Volume in Practice 06 – – – 09 # prenatals * # deliveries * (est.) # in group C/S Rate 28.6%25.5% 22.0%* (est.) Preterm Rate 8.3%7.4% 2.67%* (est.) LBW Rate 8.3%6.4% 2.67%* (est.)

Evaluation Processes in Progress IMPLICIT IMPLICIT Overall care for practice using 6 quality processes Overall care for practice using 6 quality processes Comparison of quality measures and outcomes for group versus non-group care Comparison of quality measures and outcomes for group versus non-group care Patient Satisfaction Survey Patient Satisfaction Survey Evaluation of Family Medicine Maternity Care Education with Centering Pregnancy Evaluation of Family Medicine Maternity Care Education with Centering Pregnancy

Pilot Group Versus Individual Care Patient Satisfaction and Outcomes Study Pilot Pilot First 29 patients in group care First 29 patients in group care 29 randomly selected patients in individual care during times when group care was not offered 29 randomly selected patients in individual care during times when group care was not offered Design Design Retrospective chart review (N=58) Retrospective chart review (N=58) Demographics Demographics Basic outcomes Basic outcomes Practice utilization Practice utilization Patient satisfaction survey and postpartum behaviors (N=34, 16 in group, 18 in individual) Patient satisfaction survey and postpartum behaviors (N=34, 16 in group, 18 in individual)

Demographics and Patient Outcomes Individual Care Group Care p-value N2929 Age % Multip 17.20%48.30%0.012 C/S Rate 27.60%20.70%0.539 % Medicaid 69.00%41.40%0.035 Ethnicity: White 31.00%27.60%0.649 Black Black24.10%34.50% Hispanic Hispanic37.90%24.10% Asian Asian3.50%3.50% Unknown Unknown3.50%10.30% Baby Gender (%F) 55%45%0.431 % Induction 24.10%44.80%0.097 Birth Wt % Preterm 10.30%20.70%0.277 # Prenatal Appt # No Show Appt % Postpartum visit 55.10%78.60%0.061

** p<0.05

Feedback from March of Dimes Strong evaluation component Strong evaluation component Using IMPLICIT project to structure evaluation Using IMPLICIT project to structure evaluation Currently less funding for Centering due to poor evaluation component for other projects Currently less funding for Centering due to poor evaluation component for other projects Using Centering to teach prenatal care as a way to change future doctors’ prenatal care provision Using Centering to teach prenatal care as a way to change future doctors’ prenatal care provision Impacts more than just the patients in group care Impacts more than just the patients in group care Best way to promote Centering in the future Best way to promote Centering in the future

The Future Further evaluation of impact of Centering on FM Maternity Care education Further evaluation of impact of Centering on FM Maternity Care education IMPLICIT analysis (group versus non-group) IMPLICIT analysis (group versus non-group) Patient satisfaction and practice utilization study Patient satisfaction and practice utilization study Plan to publish educational impact Plan to publish educational impact Obtaining Site Approval from CHI Obtaining Site Approval from CHI Expanding Centering to other IFH sites (Bronx, Kingston) Expanding Centering to other IFH sites (Bronx, Kingston) Train one faculty to be a Centering Trainer Train one faculty to be a Centering Trainer Expanding to Centering Parenting Expanding to Centering Parenting IMPLICIT expansion to interconception care IMPLICIT expansion to interconception care

Thank You!