1. Maine Prenatal Collaborative Susan Swartz, M.D. Judy Soper, RT(R), RDMS, BS Tim Cowan, MSPH Principal Investigator Project Director Data Analyst December 11, 2003 National Conference on Tobacco or Health

2. Tobacco and Pregnancy in Maine  ~ 1 in 5 pregnant women  38% on Medicaid

3. Target Provider Population  Prenatal Care Providers –Obstetricians –Family Practitioners –Nurse Midwives  And members of their teams –Clinical support staff –Office staff –Manager

4. Intervention Model  Clinical Collaborative –Institute for Healthcare Improvement –www.ihi.org  Chronic Care Model –Improving Chronic Illness Care –www.improvingchroniccare.org

5. What is the Collaborative? Bringing practices together to improve systems of care and patient outcomes Our goal:To enhance interventions with pregnant smokers

6. Collaborative Learning Model Planning Preparation LS 1 LS = Learning Session AP = Action Period AP 1LS 2LS 3AP 1 Continued Spread Celebration and

7. Learning Sessions  Expert knowledge in areas such as –Tobacco in pregnancy –Motivational interviewing –The 5 A’s –Pharmacotherapy  Workshops –Setting aims and goals –Using the change cycle process –Monitoring improvement  Learning from each other

8. Action Periods  Testing changes  Monitoring improvement  Conference Calls  Site visits  Assistance and support as needed

9. Chronic Care* Model Health System Self- Management Support Community Delivery System Design Clinical Information Systems Decision Support Productive Interactions Informed, Activated Patient Prepared Practice Team Functional and Clinical Outcomes * The Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues support from the Robert Wood Johnson Foundation.

10. DOPLAN ACTSTUDY Develop Your Roadmap: Identify the change you want to try, and a plan for testing it. Choose Your Path: Are the results what you want? If yes, implement the change. If no, move to a new idea. Run The Course: Take the steps that have been planned to make the desired change. Review Your Progress: Look at the data you gathered. Evaluate if the change you tried has worked. Small Tests of Change The PDSA Road Map

11. Data Collection  Tobacco Treatment Flow Sheet  Manual  Electronic Medical Record  Tobacco Treatment Database

12. Tobacco Treatment Database Option 1: Place the Tobacco Treatment Flow Sheet in a folder for end of month review. Option 2: Keep the original Tobacco Treatment Flow Sheet in the patient chart and place a copy in the folder for end of month review. Enter visit information into the database. Complete Tobacco Treatment Flow Sheet for all patients. Not At Risk At Risk Gather Information for Reporting: 1. Generate the established reports in the database for at risk patients. 2. Count the number Tobacco Treatment Flow Sheets of non- smoking patients in the folder. 3. Determine the total pregnant patient population, using your billing or internal system. Enter numbers generate d from steps above into the Access database Place a sticker in or on the chart to indicate status. (Optional)

14. Document 1

15. Run Chart Example Patients with documented tobacco status At risk patients receiving advice Current smokers assessed for interest in quitting At risk patients who received assistance during at least one visit

16. Project Evaluation - Office System  Practice inventory Observational assessment of the office practice and clinical site. Baseline/1 year.  Tobacco Related Documentation Chart audit assessment. Baseline/1 year.

17. Project Evaluation - Office System (continued)  Proactive HelpLine Referral Use of Every Mother’s Wish proactive referral form. Baseline/1 year.  Medicaid Reimbursement Use Utilization of add-on code for brief tobacco intervention. Baseline/1 year.

18. Project Evaluation - Provider/Staff Behavior  ACIC - Assessment of Chronic Illness Care –Conducted individually all team members –Modified for tobacco in pregnancy –Baseline/1 year  Individual Survey - Clinician Behavior/Beliefs –Conducted individually all clinical team members additional practice providers and clinical support staff –Baseline/1 year

19. Project Evaluation - Collaborative Process/Feasibility  Qualitative Evaluation Beliefs, needs, expectations, themes. Baseline/During/1 year.  Team Benchmarking Goal setting, measures, data collection, monthly reporting, degree of improvement. Monthly during Collaborative.  Team Satisfaction Learning sessions, materials, Collaborative staff resources, conference calls, tools, etc. Each Learning Session.

20. Project Evaluation (continued)- Collaborative Process/Feasibility  Team Participation Learning sessions, conference calls, monthly reporting. Monthly during Collaborative.  Team Function Team member evaluation, roles responsibilities, leadership identification, tool use, data collection. Baseline/1 year.  Practice Change Self reported change in knowledge, confidence, resource use, etc. 1 year.

21. Project Evaluation - Tobacco Treatment  Tobacco Treatment Database –Number of pregnant patients with tobacco status documented never quit more than 12 months quit less than 12 months quit during pregnancy current smoker –Number of at risk patients given advice –Number of current smokers assessed for interest in quitting –Number of at risk patients given assistance

22. Products  Tobacco Treatment Flow Sheet  Tobacco Treatment Database  Quick Clinician Guide  Modified collaborative model specific to tobacco in pregnancy

23. Lessons Learned and Recommendations  Recruitment less challenging that anticipated –Be prepared –Provide information relevant to the practice –Ask them about their interests/goals  Time, time, time - the evil barrier to all. –Be realistic and flexible  Jargon is a time bomb! –Remove as much as possible - keep the information straightforward  People genuinely want to do well –Be realistic with expectations