1. Let’s Get Together – a Resident Driven Group Visit Model Wendy B Barr, MD, MPH, MSCE Pam Kimball Joseph Gravel, MD Lawrence Family Medicine Residency, Lawrence, MA

2. ACTIVITY DISCLAIMER The material presented at this activity is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed but, rather, is intended to present an approach, view, statement or opinion of the faculty that may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual attending this program and for all claims that may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented at these activities. Physicians may care to check specific details such as drug doses and contraindications, etc. in standard sources prior to clinical application. These materials have been produced solely for the education of attendees. Any use of content or the name of the speaker or AAFP is prohibited without written consent of the AAFP. FACULTY DISCLOSURE The AAFP has selected all faculty appearing in this program. It is the policy of the AAFP that all CME planning committees, faculty, authors, editors, and staff disclose relationships with commercial entities upon nomination or invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

3. Objectives 1.Understand the structure and evidence-based rationale of resident-run group prenatal care and Centering Pregnancy 2.Identify the educational and administrative advantages and challenges of using a group model of care in a family medicine center. 3.Develop strategies to maximize the educational advantages and minimize the disadvantages of the group model of care for residency clinical education in their own settings.

4. Why Do Group Prenatal Care?

5. 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”

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

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

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

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

10. You are a residency coordinator... Imagine… More predictable resident scheduling Residents who want to be in clinic – Happy Residents! Meeting ACGME evaluation and systems based practice requirements Great marketing program Better birth outcomes

11. What is Centering Pregnancy?

12. A well studied standardized form of group prenatal care Has a standardized training program Now has a standardized “Model Implementation Program” (MIP) Follows specified format Has “13 Essential Elements”

13. General Program Design Initial intake to system before entry into a group (individual visit(s) with team resident(s)) – History, physical assessment/lab work completed – Case reviewed as appropriate for group care Groups of 8 - 12 women, same month/block EDD invited to group – Begin between 14-18 weeks GA – Confidentiality agreement signed – Partners encouraged to attend

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

15. Essential Elements of Centering Pregnancy 1.Health assessment occurs within the group space. 2.Participants are involved in self-care activities. 3.A facilitative leadership style is used. 4.The group is conducted in a circle. 5.Each session has an overall plan. 6.Attention is given to the core content, although emphasis may vary. 7.There is stability of group leadership. 8.Group conduct honors the contribution of each member. 9.The composition of the group is stable, not rigid. 10.Group size is optimal to promote the process. 11.Involvement of support people is optional. 12.Opportunity for socializing with the group is provided. 13.There is ongoing evaluation of outcomes.

16. The Visit Self Assessment – Take own blood pressure, weight – Write gestational age and vitals in chart – Review self assessment materials Individual Physical Assessment – individual triage with provider – Physical Exam – fundal height, fetal heart rate Education Support and Community Building Closing the Visit

17. Education Facilitated leadership, usually by health care provider Visits in circle Scheduled topics and topics from the group – Comfort issues, stress reduction, nutrition, exercise, breastfeeding, birth preparation, abuse, parenting, preterm birth, ect. Outside speakers (optional)

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

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

20. PCMH in Practice Patient is the center of the visit – Appointment based on patient EDD (not clinician assignment) – System comes to the patient Care is planned – Each visit with an agenda – Team meets to plan visit before and after visit Care is multidisciplinary Outcomes are measured and evaluated

21. Evidence for Benefits of Group Prenatal Care in a FMR

22. Centering Pregnancy Provides Better Obstetric Outcomes (SOR B) Reduce prematurity (OR 0.67 [0.44-0.98], p=0.045) Improved patient knowledge (p<0.001) Enhanced patient satisfaction (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.

23. Centering Reduces Health Disparities Ickovics JR, et.al. Group prenatal care and perinatal outcomes: a randomized control trial. Obstet Gynecol. 2007;110:330-9.

24. Single Program Evaluation Study Retrospective cohort study Pre and post intervention design – Delivered Pre-June 2008 = “Old Curriculum” – Delivered Post-June 2008 = “New Curriculum” N= 379 Compare patient outcomes and quality of care measures (how well did residents care for their patients) Barr WB, Levin M, Aslam S. Evaluation of group prenatal care-based curriculum in a family medicine residency. Family Medicine 2011; 43(10):712-7.

25. Results – Patient Care Outcomes Old Curriculum (N=184) New Curriculum (N=195) p-valueUnadjusted ORAdjusted OR* Adjusted p- value LBW Rates8.47%4.76%0.1520.54 [0.20, 1.36]0.43 [0.18, 1.06]0.067 PTB Rates8.33%4.15%0.0930.48 [0.17, 1.23] 0.39 [0.15,0.98] 0.045 Cesarean Rate 26.92%17.53%0.0280.58 [0.34, 0.97] 0.61 [0.37, 1.01] 0.053 *Adjusted for multiparous and insurance status Barr WB, Levin M, Aslam S. Evaluation of group prenatal care-based curriculum in a family medicine residency. Family Medicine 2011; 43(10):712-7.

26. Patient Satisfaction Evaluation Single program evaluation Telephone Survey with concurrent retrospective chart review Survey Population – All women delivered by family medicine practice between June 2008-June 2010 – Survey timing 2-10 months postpartum – Conducted by research staff not involved in pregnancy care

27. Benefits of Group Care – Quality Measures Improved patient satisfaction Higher postpartum visit rate Higher rate of “adequate prenatal care” Lower rate of “walk-in” visits

28. Conclusions Group prenatal care taught in a family medicine residency program was associated with: – 39% reduced odds of cesarean section – 61% reduced odds of preterm birth – Improved patient satisfaction – Improved quality measures such as postpartum visit rate Group visits increased the continuity patient volume in a residency practice

29. Resident Experience Facilitative Training More time with patients Better understanding of patients’ wishes and concerns Promote/experience natural childbirth and physiologic birth More one on one time with preceptor Team building with co-resident More enjoyable and relaxing Learning in an evidence-based model Modeling through improved outcomes

30. 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

31. A Resident Centered Group Prenatal Visit Model

32. General Structure of Program Faculty are trained (Centering Pregnancy Workshop) and assigned to co-facilitate groups (faculty continuity within group) Divide year by number of residents in a class = Groups/year (example 8-8-8 program, has 8 Groups/year) Every resident co-facilitates a group for their continuity OB patients 2 groups throughout their residency – R1/R2 year and R3 year Group session replaces a continuity clinic Patient numbers count for one resident or both residents (RRC exemption)

33. Curricular Model Centering Pregnancy/group prenatal care didactic for residents Group facilitation workshop for junior residents All residents facilitate 2 Centering Pregnancy groups in their residency Each group facilitated by a trained attending, R3, and R1/R2 resident (continuity residents) R3 resident acts as mentor to R1/R2 resident and as lead facilitator Facilitator guides are read and reviewed by residents as go through group Post-group precepting includes OB chart review/QI review

34. Centering Pregnancy at Institute for Family Health/Beth Israel Residency in Urban Family Practice

35. Timeline Started first pilot group in 2006 4 pilot groups over 2 academic years 2008-2009: Full implementation as requirement for all residents – 8 groups a year 2008 & 2010 March of Dimes Chapter Community Grants

36. Group Model Official Centering Pregnancy – 10 prenatal visits starting at ~16 weeks – Social “postpartum” visit to meet the babies All patients in practice assigned to residents for prenatal care – Residents assigned to “blocks” of a 6 week EDD range – “OB Call” covered by continuity resident team Practice covers ~100 deliveries/year

37. Beth Israel Curriculum Model 3-4 Centering Pregnancy trained faculty preceptors 1-3 Family Medicine faculty doing intrapartum care Annual talk on Centering Pregnancy concepts to residents All residents facilitate 2 Centering Pregnancy groups in their residency – Each group facilitated by a trained attending, R3, and R2 resident (continuity residents) – R3 resident acts as mentor to R2 residents and lead facilitator – Facilitator guides are read and reviewed by residents as go through group Residents participate in OB chart review sessions

38. Resources/Support Staff Americorps Volunteer – Prenatal Coordinator – Maintains Prenatal registry – Recruits and tracks patients for group visits – Outreach prenatal patients – Schedules patients for group visits – Assists with visit planning, including preparing educational materials – Assists with visits Set up and take down Assist facilitators during visit – Cross-trained as labor doula

39. Group Prenatal Visits at Lawrence Family Medicine Residency

40. Timeline Started first pilot group in 2010 5 pilot groups over 3 academic years 2012-2013: Full implementation as requirement for all residents – 10 groups a year (11 in the first year to accommodate all residents) No direct grant funding

41. Group Model Modeled on Centering Pregnancy – 9 prenatal visits starting at ~20 weeks – 10 th visit the official Postpartum Visit (can add WCV if needed) Attendings and residents are assigned and care for prenatal patients – Residents follow own patients if become pregnant – Unassigned /new prenatal patients are assigned to group prenatal residents’ team (5 week EDD block) – Residents and attendings are encouraged to refer patients to group visits and share care with group prenatal team – OB Call covered by Maternity Care inpatient team, continuity resident called in for deliveries Practice covers ~800 deliveries/year

42. Current Model for LFMR 5-6 Faculty (plus 2 OB Fellows/year) Centering Pregnancy trained preceptors R1 didactic workshop session (3-4 hours) on prenatal group facilitation All residents facilitate 2 prenatal groups (based on a CP model) in their residency – 10 sessions per group (starting at ~20 weeks EGA, last visit 4-6 weeks postpartum) – Each group facilitated R1/R2 and R3 residents (continuity residents) – R3 resident acts as mentor to R1/R2 residents and lead facilitator – LFMR Facilitator guides are read and reviewed by residents as go through group

43. Resources/Support Staff Head MA for Group Prenatal Visits – Assist with scheduling and recruitment – Assist with follow up of patients in group visits – Maintains registry of group patients from recruitment to delivery/postpartum PSR for Group Visits – Assist with scheduling and recruitment – Registers patients during group visits – Calls patients day before for reminder calls – Will help schedule patients for other internal appointments if identified early in group session Residency Administrative Assistant – Group room set up and clean up – Assists with preparation of education materials

44. Centering Pregnancy Or Not

45. What are the Advantages being a Centering Pregnancy Program? Part of standardized program Well studied with proven clinical benefits Standardized patient education materials (English and Spanish) Accreditation process Support for implementation through Model Implementation Program (MIP) March of Dimes grant support for implementation Ability to collaborate in Centering studies (scholarly activity)

46. Why Not Be Centering Certified? COST/MONEY $$$$$$$ Limitations on flexibility in implementation and use of materials More regulation to follow (if you want to be certified)

47. Implementation of Group Prenatal Program

48. Suggested Steps Get key faculty and clinical staff (nursing) trained in group prenatal care (Centering Pregnancy Two-Day Workshop) Pilot 1-2 groups with motivated residents and faculty Make plan to implement group prenatal care that involves all residents and is available to all patients Make prenatal groups = continuity clinic (the resident leads the group and is the clinician with faculty as preceptor) Have a prenatal coordinator (nurse or other staff) to coordinate groups (can also help with general prenatal case management)

49. Lessons Learned You will need to plan group assignments 16-18 months in advance (or more) – Group assignments will then help drive block schedules Some or all continuity patients will deliver in a defined time period (the due dates of the group) Program mindset needs to be Prenatal Group = Continuity Clinic Clinic institutional support (especially coordinator time) is critical for sustainability

50. Example of 10 Block Schedule (10-10-10 Program) JanFebMarAprMayJuneJulyAugSeptOctNovDec Group 1-803/03/12-04/06/1228w32w36w40w 30w34w38w Group 1-904/07/12-05/11/1224w28w32w36w40w 30w34w38w Group 1-1005/12/12-06/16/1220w24w28w32w36w 30w34w38w 40w Group 2-16/23/12-8/3/12 16w20w28w30w34w38w 24w 32w36w40w Group 2-2 8/4/12 - 9/7/12 16w20w24w30w34w38w 28w32w36w40w Group 2-3 9/8/12 - 10/12/12 16w20w24w28w32w36w40w 30w34w38w Group2-4 10/13/12-11/16/12 16w20w24w28w30w34w40w 32w36w 38w Group 2-5 11/17/12 - 12/22/12 16w20w24w28w30w34w38w 32w36w40w Group 2-6 12/22/12 - 2/1/13 16w20w24w30w34w 28w32w36w Group 2-7 2/2/13 - 3/8/13 16w20w24w28w 30w Group 2-8 3/9/13 - 4/12/13 16w20w24w Group 2-9 4/13/13 - 5/17/13 16w20w Group 2-105/18/13 - 6/21/13 16w

51. Example 8 Block Schedule (8-8-8) Program JanFebMarAprilMayJuneJulyAugSeptOctNovDec Group 1-512/11/09-1/27/10 40w Group 1-61/28/10-3/14/10 36w40w 38w Group 1-73/15/10-4/26/10 28w30w34w38w 32w36w40w Group 1-84/27/10-6/1/10 20w24w30w34w38w 28w32w36w40w Group 2-16/1/10-7/16/10 16w20w24w28w32w36w 30w34w38w 40w Group 2-27/17/10-8/31/10 16w20w24w28w32w36w40w 30w34w38w Group 2-39/1/10-10/16/10 16w20w24w28w32w38w 30w34w40w 36w Group 2-410/17/10-12/1/10 16w20w24w28w30w34w38w 32w36w40w Group 2-512/2/10-1/16/11 16w20w28w30w34w38w 24w 32w36w40w Group 2-61/17/11-3/3/11 16w20w28w32w 24w30w34w Group 2-73/4/11-4/17/11 16w20w28w 24w Group 2-84/18/11-6/1/11 16w20w

52. Implementation Resources Centering Healthcare Institute (Centering Pregnancy) – Start up Guide/Plan: http://www.centeringhealthcare.org/pages/centering-model/group-start-up.php http://www.centeringhealthcare.org/pages/centering-model/group-start-up.php – Centering Pregnancy Basic Workshops: http://www.centeringhealthcare.org/pages/upcoming-workshops.php http://www.centeringhealthcare.org/pages/upcoming-workshops.php March of Dimes Community Chapter Grants – Look at state chapter website: http://www.marchofdimes.com http://www.marchofdimes.com Family Medicine Digital Resource Library (www.fmdrl.org)www.fmdrl.org – Many group prenatal/Centering Pregnancy in residency resources

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

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

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

57. Benefits of Group Care – Decreased Cesarean Rate in Practice Compared to Hospital and National Rates

58. Benefits of Group Care – Increased Patient Volume

59. Results – Health Care Utilization and Satisfaction Individual Care (N=125) Group Care (N=123) p-value Initiate Prenatal Care12.43wk9.02wk<0.001 Total Prenatal Visits12.1visits15.02visits<0.001 No Shows2.66visits2.15visits0.112 Walk-in visits1.5visits0.98visits0.0284 Adequate Prenatal Care(>8 visits)81.63%95.08%0.001 Postpartum Visit (%)57.38%71.31%0.023 Patient Satisfaction (1-10 scale)7.949.20<0.001