1. National Capital Strong Start
Health Services For Children with Special Needs, Inc.
(HSCSN) OB/GYN Provider Forum
Gabriela Garcia
Director, Center for Perinatal Advocacy at Providence
September 24, 2013

2. Project Aim: By 2016 the National Capital Strong Start program will improve birth outcomes by achieving a 20% decrease in pre-term birth and low birth weight infants as compared to the DC 2012 rates.

3. Objectives
By the end of this presentation, the listener will be able to:
Identify models of enhanced prenatal care aimed at prematurity
Identify local implementation of these models in the District

4. How did we get here?

5. Significant Disparities
Wards 5, 6, 7 and 8, where 77% of residents are African American and rates of pre-term birth and low birth weight exceed the national average.
The percentage of the population enrolled in Medicaid is higher in DC than in any other state, with 28% of DC residents and 61% of District children relying on the Medicaid program.
In 2009, low birth weight infants accounted for 10.3%, of births in the District
The District’s 2009 preterm birth rate was 14.2%

6. Historic Partnership of 13 organizations
Howard University Hospital
Medstar Georgetown University Hospital
Medstar Washington Hospital Center
Providence Hospital
Community of Hope’s Family Health and Birth Center
Mary’s Center
Unity Health Care
Chartered Health Plan
Health Services for Children with Special Needs, Inc.
United Healthcare Community Plan
DC Department of Health’s Center for Policy, Planning, and Evaluation
DC Department of Health Care Finance, and
Healthy Babies Project

7. Enhanced Prenatal Care

8. CenteringPregnancy®
Enhanced Prenatal Care through Centering/Group Visits – group prenatal care that incorporates peer-to-peer interaction in a facilitated setting for health assessment, education and psycho-social support
provided at Providence Hospital’s Center for Life and Washington Hospital Center

9. Enhanced Prenatal Care at Birth Center
Enhanced Prenatal Care at Birth Center – comprehensive prenatal care facilitated by teams of health professionals including peer counselors. Services include collaborative practice, intensive case management, counseling and psycho-social
Support to be provided at Community of Hope’s Family Health and Birth Center

10. Enhanced Maternity Care at Maternity Care Homes
Enhanced Prenatal Care at Maternity Care Homes – enhanced prenatal care including psychosocial support, education and health promotion in addition to traditional prenatal care. Services provided will expand access to care, improve care coordination and provide a broader array of health services
Provided at Howard University Hospital and Unity Health Care, Mary’s Center

11. Overview of NCSS Program
CMS Innovations Center awarded $1.8 million to Providence Hospital Foundation
The NCSS project will serve 3,705 Medicaid pregnant women and their infants over three years.
The National Capital Strong Start Program’s Operation definition for high-risk preterm birth is Medicaid eligibility + at least 1 IOM risk factor(s).
Each provider will make the initial assessment and a CMS intake form (a 3rd trimester, 6-week postpartum form, and exit form are still forthcoming)
Risk factors and utilization are defined by model

12. Beyond the traditional medical model
Patient Support through additional psycho/social support systems
Addresses medical, behavioral, and psychosocial factors present during pregnancy that contribute to preterm-related poor birth outcomes

13. Medicaid Birth Served by Model
Figure C. Medicaid Births Served by Model
Year One
Year Two
Year Three
Total
CenteringPregnancy®
Providence Hospital
100
300
Washington Hospital Center 80
130
310
Birth Center
Community of Hope FHBC
105
155
160
420
Maternity Care Home
Howard University Hospital
277
253
830
Mary’s Center
200
225
250
675
Unity Health Care
170
500
1,170
932
1,380
1,393
3,705

14. United Healthcare Community Plan Chartered Health Plan
Grant Application: Providence, Providence Health Foundation Grant Convener: Providence, The Center for Perinatal Advocacy at Providence
(Total Expected Patients Served 3705: Yr 1=932, Yr 2=1380, Yr 3=1393)
Maternity Care Home
(Yr 1: 647, Yr 2: 1025, Yr 3: 1003)
United Healthcare Community Plan
Chartered Health Plan
Birth Centers
(Yr 1: 105, Yr 2: 155, Yr 3: 160)
Community of Hope
(105/155/160)
CenteringPregnancy®
(Yr 1: 180, Yr2: 200, Yr3: 230)
Providence Center for Life
(100/100/100)
Data Indicators (5)
1) gestational age at delivery
2) birth weight
*3) entry into prenatal care/number of visits
*4) maternal/fetal complications and c-section
*5) history of pre-term birth
DC Department of Health, Center for Policy, Planning, and Evaluation
Mary’s Center†
(200/225/250)
Unity Health Care†
(170/500/500)
Howard University Hospital
(277/300/253)
Medstar Washington Hospital Center (80/100/130)
DC Department of Health Care Finance
Medstar Georgetown University Hospital
Health Services for Children with Special Needs, Inc
CMS
CONTRACTOR
Grant Manager

15. Services at CenteringPregnancy® Sites
CenteringPregnancy® model, as approved by the Centering Institute is a multifaceted model of group care that integrates the three major components of care: health assessment, education, and support.
Groups of 8-12 women with similar gestational ages meet together, learning care skills, participating in a facilitated discussion, and developing a support network with other group members.
8 to 10 sessions that are 90 to 120 minutes in length. Jointly facilitated by a certified Nurse-Midwife and another trained professional, usually a social worker.
Each session begins with a private medical assessment completed in a separate part of the room where the mother shares problems and concerns with a health professional and the health status of the baby is evaluated.
Women participate actively by taking their own blood pressure and weight and recording these indicators in their charts.
The medical assessment is followed by a facilitated group educational presentation where women receive information and instruction on a variety of subjects. Curriculum includes: nutrition/exercise, pregnancy discomforts and interventions, family role models, sexuality, childbirth preparation, transition to parenthood, breastfeeding and baby care.

16. Services at Birth Center
NCSS will enable certified Nurse Midwives through a patient navigator at FHBC to provide prenatal care to 420 Medicaid women over three years.
Women begin their participation with an orientation to FHBC, which includes a first visit with a midwife to ensure that patients are fully educated on the model and are medically appropriate for a birth center. For the first two trimesters of pregnancy, women will have monthly individual visits with a midwife, with support from the patient navigator.
COH will enhance their volunteer doula program and hire a patient navigator to support women through their pregnancy. The navigator will also assist with the social needs that high risk women face at FHBC which may lead to pre-term deliveries or low birthweight babies.
The Patient Navigator will work with the midwives, medical assistant, and breastfeeding peer counselors, to ensure that mothers are making appointments, getting needed referrals, and getting the social services support they may need.

17. Services Maternal Home Model: 9 Sites
Model based on National Center on Quality Assurance (NCQA) Patient Centered Medical Home (PCMH) model of care for primary care and Geisinger Health Systems ProvenCare Perinatal model.
Screen for behavioral risk factors associated with pre-term birth, including nutritional status and history of smoking, alcohol and substance abuse;
Coordinated care from an interdisciplinary team of on-site staff, including medical, nursing, and health promotion professionals;
Access to Maternity Care Home (MCH) Navigators, who will help to engage and educate participants, providing structured brief interventions focused on the importance of eliminating alcohol and substance abuse and linking them to smoking cessation, nutrition and other social services;
Culturally and linguistically appropriate support including translation services; and
Access to a 24/7 clinician support line.  

18. Next Steps toward implementation
Institutional Review Board, Final details
Subcontracting to partner sites (5)
Data and Reporting to CMS

19. References
Henry J. Kaiser Family Foundation State Health Facts. Available at:
Working together for Health, Medicaid Annual Report FY2008, DC Department of Health Care Finance. Pg 4 and 10. Available at:
Henry J. Kaiser Family Foundation. State Health Facts, DC: Preterm Birth as a Percentage of all births, Available at:
Henry J. Kaiser Family Foundation. State Health Facts, DC: Birth of Low Birthweight as a Percent of All Births by Race/Ethnicity, Available at:
Centering Healthcare Institute, Centering Pregnancy Overview, available at:
Chasnoff, I; McGourty, R., Pre-Treatment: A Brief Intervention for the Primary Care Setting. National Training Institute, 2003.

20. Thank you! Questions?
Gabriela A. Garcia Director, Center for Perinatal Advocacy at Providence