1. CDC Levels of Care Assessment Tool
Andrea Catalano, MPH
West Virginia Perinatal Summit
November 15, 2018

2. Background
My background and MHT.

3. Risk-Appropriate Care
Strategy promoted in 1976 March of Dimes report*
Simple concept quickly embraced by many states
Enhanced by
Public health research
Implementation complicated by
Reimbursement policies
Hospital competition
Regional context
Pregnant woman & neonate
Appropriate level of care facility
Improved outcomes
Risk-appropriate care is an approach designed to improve outcomes for moms and babies by ensuring they receive care at a facility that aligns with their risk. The concept has been around for several decades and a meta-analysis found improved outcomes for high-risk neonates when born at level III or IV hospitals, further supporting the need for regionalized care. However, there are several barriers to implementing this strategy, as you can see here.
* Committee on Perinatal Health. Toward Improving the Outcome of Pregnancy:
Recommendations for the Regional Development of Maternal and Perinatal Health Services.
White Plains, NY: March of Dimes National Foundation, 1976.

4. Policy Based on Guidance
Challenges
Reimbursement, competition, landscape
Lack of granularity = Inconsistent policies
AAP guidelines + X/Y/Z = State policy A/B/C*
Absence of maternal level criteria comparable to neonatal (Until 2015**)
As states and other jurisdictions have attempted to navigate levels of care by creating specific policies, some challenges have arisen. The current guidance lacks specificity around the criteria of availability of specialists and equipment, leaving room for a great deal of personal interpretation and inconsistent policies which are difficult to compare.
States often take the AAP guidelines and then add something (X, Y, Z) additional and then make a state policy out of that. It aligns with research by Blackmon, Barfield and Stark that found extensive differences in criteria and definitions for levels of neonatal care. ACOG and SMFM published the levels of maternal care guidance in 2015 in response to concerns over rising maternal morbidity and mortality in the US.
* Blackmon LR, Barfield WD, Stark AR. Hospital neonatal services in the United States: variation in definitions, criteria, and regulatory status, J Perinatol Dec;29(12):788-94
** Levels of maternal care. Obstetric Care Consensus No. 2. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:502–15

5. A Perfect Storm
These challenges have created a perfect storm where states and other jurisdictions find themselves struggling to navigate the sea of risk-appropriate care. But never fear as we have George Clooney and LOCATe to save the date and guide us to sunny skies.

6. What is LOCATe? Levels of Care Assessment Tool
Produces standardized assessments
Fosters collaboration across borders
Strengthens evidence for increased specificity in criteria
3) Facilitates stakeholder conversations
Increases (common) understanding of landscape
Data driven improvements in facilities & systems
…while, minimizing burden on respondents
The levels of care assessment tool (LOCATe) was designed by staff at CDC’s Division of Reproductive Health in response to a need identified by states and other jurisdictions to assess levels of care for facilities in alignment with national guidelines published by AAP and ACOG/SMFM. Beyond assessing levels, LOCATe collects data for future analyses to address gaps in the current evidence. This will allow for more specific wording in future versions of the guidelines. While LOCATe is not comprehensive, it allows for stakeholders working in risk-appropriate care to come to the table and make data-driven decisions.

7. Development of LOCATe 2013-Pilot testing 2014-Field testing
Several facilities in 5 states
2014-Field testing
All facilities in 2 states, initially
Then, staged roll-out with additional states
2017-Version 8
Each state implementation provides feedback
V8 includes:
Questions on drills & protocols
More refined wording
LOCATe was initially designed in 2013 and pilot tested in several facilities in 5 states. In 2014 it was field tested in 2 states with a goal of 100% birth facility participation. Additional state roll-out occurred throughout 2014 and beyond. Each state implementation provides feedback and the ability to refine the tool and as of 2017, LOCATe is in version 8.

8. LOCATe Content

9. LOCATe Content Includes questions about:
Hospital equipment and staffing
Subspecialists and their availability
Self-designation of level of care
Volume of procedures
Pediatric Surgery
Ventilation for neonates
Transports and facility-level statistics
Here are some of the content questions included as part of LOCATe. As previously mentioned, some of the data collected isn’t used to assess the level of care but can be utilized to analyze on differences in outcomes or produce other statistics around risk-appropriate care.

10. The LOCATe Process

11. The LOCATe Process Build support for participation
Identification of champion
Stakeholder engagement
Foster relationships with facilities
Implementation & data collection
Champion provides facilities with LOCATe link and follows up with non-respondents
Analyses & dissemination
Champion sends data to CDC to assess levels
CDC provides results back to champion to use and share as desired
How does it actually work? Important pieces of highlight: building support for participation can take time. The more thoughtful you are in this process, the higher response rate you will likely have. Data is collected by champion and shared with us to assess levels using algorithm. Data belongs to champion.

12. The LOCATe Assessment 2015 ACOG/SMFM Guidance 2012 AAP Guidance
LOCATe algorithm
SAS Program
A note about the development of the LOCATe logic. It is in alignment with the 2012 AAP and 2015 ACOG/SMFM guidelines. We have also programmed the logic into a SAS program for automated assessment.

13. LOCATe Jurisdictions*
Current LOCATe family.
*as of 11/2018

14. Analysis & Dissemination

15. Analysis Opportunities
State level report
Summary of guidelines
Aggregate information by levels
Merge levels with public health surveillance data
Hospital discharge records (Severe Maternal Morbidity and neonatal morbidity)
Vital Records (neonatal and post neonatal mortality)
Examine outcomes between and within levels of care and by specific capabilities
The possibilities for analysis with LOCATe data are endless and it is dictated by the needs and priorities of the implementation team and their jurisdiction. Here are some examples.

16. Dissemination Opportunities
Webinar for Hospitals
High-level information & overview
Individual Hospital Reports
Describe facility’s levels and reasons for variation from expected levels
Discuss quality improvement opportunities
Patient safety bundles
Partner with other organizations to strategize activities on risk-appropriate care in state/jurisdiction
Equally as important as analysis is the dissemination of LOCATe results to both the facilities and other stakeholders in risk-appropriate care. The results can be shared both as high-level aggregate information and hospital specific.

17. Future Activities Multi-jurisdiction analysis LOCATe toolkit
ACOG Levels of Maternal Care Verification
Program
More Technical Assistance Materials
Emergency preparedness
Quality Improvement
Opportunities for telemedicine use

18. How does this all fit together in the bigger picture of improving the health of women.

19. LOCATe is another data point which allows states to make data driven decisions about programs and interventions.

20. Andrea Catalano acatalano@cdc.gov
Thank you! Questions?
Andrea Catalano
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.