1. Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant Mortality
Secretary’s Advisory Committee on Infant Mortality
November 15, 2012
Reem M. Ghandour, DrPH, MPA
COIN Coordinator / Senior Public Health Analyst
U.S. Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health Bureau
Office of Epidemiology and Research
Thank you for this opportunity to provide an UPDATE on the Collaborative Improvement & Innovation Network to Reduce Infant Mortality as a lot has happened since we last spoke about this initiative in July.
In the simplest terms, this is an initiative designed to bring the science of quality improvement and collaborative learning to bare on the challenge of infant mortality beginning in the 13 southern states.

2. What is a CoIN?
A CoIN, or Collaborative Innovation Network, has been described as a team of self-motivated people with a collective vision, enabled by the Web to collaborate in achieving a common goal by sharing ideas, information, and work.1
Key Elements of a CoIN
Being a “cyber-team” (i.e. most CoIN work will be distance-based);
Innovation comes through rapid and on-going communication across all levels;
Work in patterns characterized by meritocracy, transparency, and openness to contributions from everyone.
Adapted to reflect focus on both innovation and improvement yielding a Collaborative Improvement & Innovation Network to Reduce Infant Mortality.
JUST AS A REMINDER….this initiative is grounded in the model developed by Dr. Peter Gloor and is highly influenced by a couple of key characteristics of this model:
COIN relies on people working in a CYBERTEAM. This is important b/c most of us still relay on relationships that are based on face to face contact and the trust that that can engender. We’re asking people to collaborate successfully in a whole new way.
It is a model that requires everyone to be part of the solution – ex of clinical setting.
IN IT’S IDEAL FORM, Interactions and team processes are characterized by transparency and meritocracy WHICH ENABLES that diffuse communication and decision-making.
AS A REMINDER….WE’VE ADAPTED….
1 Gloor PA. Swarm Creativity: Competitive Advantage through Collaborative Innovation Networks. New York: Oxford University Press, 2006.

3. Infant Mortality CoIIN: History and Vision
Started in Southern states:
Born out of January 2012 Infant Mortality Summit in New Orleans, LA for Regions IV and VI as well as previous state-level work by ASTHO and March of Dimes.
Designed to address stated needs :
Support collaborative learning, innovation, and quality improvement efforts to reduce infant mortality and improve birth outcomes;
Apply evidence-based strategies to reduce infant mortality;
Stimulate action across states, among many partners.
Lifespan: months (beginning July 2012) with nation-wide expansion planned.
Developed and implemented in ongoing partnership with ASTHO, AMCHP, March of Dimes, CityMatCH, CMS, and CDC and other public and private partners.
Foci, activities, and outcomes are Team driven.
In the most concrete sense, this was born out of the January summit that occurred last winter in NoLa. + previous work by ASTHO and others.
Underscore – we moved very quickly on this initiative in part to be responsive to the states that participated in the January Summit and in part to build on the momentum that we anticipated coming out of the June 14th Announcement by Sec Sebelius at the Child survival Call to Action for a National Strategy to reduce infant mortality.

4. CoIIN Design Strategy Teams State Teams
Common Strategies for Regions IV and VI
Promote smoking cessation
Expand Interconception Care in Medicaid
Reduce elective deliveries
Enhance perinatal regionalization
Promote safe sleep
Strategy Leads (2-3 topical experts)
Data and/ or Methods Experts
Staff support (MCHB & Partner Organizations)
State Representatives Average people
Strategy Teams
State Health Officials
MCH staff
Medicaid staff
Private partners
Average 7-15 people
State Teams
What’s happing and Who is doing it.
Private Partners: academic experts, March of Dimes, clinical providers, health plans, etc.
State Team members comprise the bulk of the membership of the Strategy Teams that work together to tackle these 5 common areas identified by the states a little over a year ago.
Contract Team with expertise in quality improvement + Advisory Panel of Experts

5. Define Scope and Nature of the Problem Build and Sustain Cyberteams
CoIIN: Work to Date
Define Scope and Nature of the Problem
Establish quality improvement Aims for each Strategy.
Aims
Identify state-level opportunities to achieve Aims.
Strategies
Select measures to track progress towards Aims over the next mo.
Measures
Build and Sustain Cyberteams

6. Aims & Strategies: Increase Safe Sleep Practices
AIM: Increase infant safe sleep practices by 5% by December 2013 in Regions IV and VI states and reduce disparities in sleep-related infant deaths.
Infant care-giver KAB and practices
Standardized training within provider systems
Strategic alliances
STRATEGIES
Infant Caregiver Behavior:
-Target Audience: day care workers, child care providers, churches, baby sitters, etc.
-Focus: Knowledge, attitudes and beliefs in support of safe sleep behavior, and increase in adoption of safe sleep promotion practices
Training Standardized:
-Target Audience: Systems that house OB, Pediatrics, nursing staff, discharge planners, home visitors, clinic staff, etc.
-Focus: Enact policies through these provider systems that require the modeling and promotion of safe sleep recommendations
Strategic Alliances:
-Target Audience: Non-traditional partners like AARP, Sororities, Civic Groups, students, volunteers, Girl Scouts, etc.-
-Focus: Expand network of organizations that endorse AAP safe sleep recommendations

7. Aims & Strategies: Expand Interconception Care
AIM: Modify Medicaid policies and procedures in 5-8 Southern states by December 2013 in order to improve access to and financing of postpartum visits and interconception care case management for women who have experienced a Medicaid financed birth that resulted in an adverse pregnancy outcome.
Medicaid eligibility policy
Medicaid program design & innovation
Medicaid administrative processes
Provider KAB & Practices
Consumer KAB & Utilization
STRATEGIES
Medicaid eligibility policy
1115 Waiver (“interpregnancy”) – GA and LA “mentoring” other states
Optional eligibility expansion for women (now)
ACA Medicaid Expansion January 2014 and beyond
Medicaid program design & innovation
Targeted (medical assistance) case management
Administrative case management
Medicaid health homes for women with chronic (and mental) health conditions
Medicaid administrative processes
Medicaid billing codes and modifiers
Reimbursement for services (e.g., case management)
Medicaid data (including linkage to vital stats)
Provider KAB & Practices
Education; Medicaid provider guidance and manuals
Emphasis on postpartum visit, including tools and performance monitoring with HEDIS measure
Systems coordination / integration (e.g., referral patterns, safety net, Healthy Start)
Consumer KAB & Utilization
Consumer information materials & social marketing campaigns (including postpartum visits, RLP, family planning, ICC)

8. Aims & Strategies: Enhance Perinatal Regionalization
AIM: By December, 2013, increase to 90% or by 20% above baseline, mothers delivering at appropriate facilities to include infants less than 32 weeks gestation and/or less than 1500 grams.
Data
Maternal Care
Policy and Incentives
Guidelines for Levels of Care
STRATEGIES
Data
Standardize reporting of national performance measure #17
Standardize Analysis of data (VLBW by place)
Maternal Care
Develop guidelines for maternal care with other organizations ACOG, Maternal Fetal Medicine AWHONN (based on existing guidelines)
Identify barriers to implementation
Develop toolkit
Policy and Incentives
Address hospital reimbursement for NICU babies born in Level II hospitals
Address “bundling’ issues related to transport (unbundle transport)
Guidelines for Levels of Care
Standardize Levels of Care for all states
Create back-up procedures in addition to transport, if birth is in hospital with insufficient level of care.

9. Aims & Strategies: Increase Smoking Cessation
AIM: To decrease the tobacco smoking rate by 3% among pregnant women in the States of Regions IV and VI by December 31, 2013.
Provider KAB & Practices
Consumer KAB & Practices
Medicaid Policy
STRATEGIES
Provider KAB & Practices
Provider awareness of resources to support tobacco use cessation
Provider education and training around evidence-based cessation interventions
Support SYSTEMS and ENVIRONMENTAL CHANGES that enable implementation of smoking cessation best practices at the provider level i.e. protocols
Consumer KAB & Practices
Ensure the maximum (or full range of) evidence-based, Quitline tobacco cessation service bundle is available to pregnant women who smoke
Increase knowledge and use of Quitlines by pregnant and post-partum women
Medicaid Policy
Conduct a State inventory of current policies / practices regarding Medicaid’s expanded coverage of tobacco cessation services for pregnant and post-partum women
Develop alliances and cooperative relationships with State Medicaid programs
Endorse a standard of Quitline benefits/services for pregnant and post-partum women and encourage State Medicaid programs to adopt
Encourage State Medicaid programs to support State Quitlines through use of Medicaid administrative match funds

10. Aims & Strategies: Reduce Elective Deliveries < 39 wks
AIM: By August, 2013, reduce the proportion of non-medically indicated deliveries < 39 weeks by 33% in the Region IV and VI states.
Committed, Collaborative Leadership & Momentum
Data
Policy & Environmental Change
Provider KAB & Practices
Consumer KAB & Practices
Leadership & Momentum:
Identify leaders/champions
Have the right partners at the table
Public-Private Collaboration
Make a credible case for change: the business case and the human case
Data
Assess the current situation/establish baseline and gaps
Define standard data sources and measures, timelines
Improve the quality and timeliness of data
Policy & Environmental Change
Change Medicaid payment practices
Recommend hard stop policies if voluntary not successful
Educate legislators and advocates
Provider KAB & Practices
Identify a physician champion
Training for facility leaders re: ACOG guidelines, outcomes
Involve Quality and Risk Management staff
Consumer KAB & Practices
Public education/social marketing about LPT brain development, what is term, risks of early ED
Develop list of myths and responses
Coordinate messages at federal/national and state/community level

11. CoIIN: Next Steps (6 months)
Region IV & VI Strategy Teams to refine Aims, Strategies, Metrics, Driver diagrams;
Implement strategies at State level;
Track process and outcome (short and midterm) measures;
Plan for 2nd face-to-face meeting (i.e., Learning Session);
Expand to Region V (March 2013) and other Regions.

12. CoIIN: Summary
A new MCHB-HRSA partnership to accelerate improvements in infant mortality.
Designed to help States:
Innovate and improve their approaches to reducing infant mortality and improving birth outcomes through communication and sharing across state lines;
Use the science of quality improvement and collaborative learning to improve birth outcomes.
Part of a portfolio of Public/Private and MCHB efforts to improve birth outcomes.

13. Contact Information
Reem M. Ghandour, DrPH, MPA
Senior Public Health Analyst
Maternal and Child Health Bureau