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Ohio Perinatal Quality Collaborative
Through collaborative use of improvement science methods, reduce preterm births & improve perinatal and preterm newborn outcomes in Ohio as quickly as possible.
TheOhioPerinatalQualityCollaborative
Obstetrics
ANCSforwomenatriskforpreterm
birth(240/7 ‐ 336/7)
39‐WeekScheduled
Deliveriesw/omedicalindication
IncreaseBirthDataAccuracy&Onlinemodules
Spreadtoallmaternityhospitalsin
Ohio
ProgesteroneforPretermBirthRisk
LARC
Neonatal
BSI:Highreliability
maintenancebundle
NeonatalAbstinenceSyndrome
MOMS+
Humanmilkininfants22‐29week
GA
NICUGradsProject
SmokeFreeFamilies
https://opqc.net
Age-adjusted drug overdose death rates, by state: United States, 2016
NOTES: Deaths are classified using the International Classification of Diseases, Tenth Revision. Drug-poisoning (overdose) deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.
SOURCE: NCHS, National Vital Statistics System, Mortality
Incidence of Maternal Opiate Use and NAS Since 2004
Winkelman, Tyler NA, et al. "Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014."
Pediatrics 141.4 (2018): e20173520.
• From 2004 to 2014, the rate of U.S. infants diagnosed with opioid withdrawal symptoms, known as neonatal abstinence syndrome (NAS), increased 433%, from 1.5 to 8.0 per 1,000 hospital births.
• However, the increase was even more stark in state Medicaid programs -- rising from 2.8 to 14.4 per 1,000 hospital births. Medicaid, a public health insurance program, covered more than 80% of NAS births nationwide in 2014.
Drug Use or Dependence Diagnosis at Time of Delivery
0
1,000
2,000
3,000
4,000
5,000
6,000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Marijuana
Opioid
Cocaine
Other (Amphetamine Psychostimulant, Hallucinogens and Sedatives)
Total Number Delivering Mothers Diagnosed with Dependence
Source: Ohio Hospital Association
Increases in Incidence of NAS
7
• From 2006 to 2017, there were approximately 15,441 hospital discharges due to NAS among Ohio residents in Ohio hospitals; 1,935 were in 2017.
• The hospital discharge rate for NAS in 2017 (140 per 10,000 live hospital births) was approximately 6.3 times the rate in 2006 (20 per 10,000).
MOMS 1.0ODMHAS & ODM
sponsored 2014-2016BH driven
4 regional sites
MOMS “Plus”ODM sponsored
OPQC led (mentor/partner)2018 - current
OB provider is team lead29 sites
MOMS 2.0ODMHAS sponsored/led
2018 - currentMAT driven
10 sites
Improved care for
the pregnant patient
with OUD and her infant
MOMS programs in Ohio
MOMS Project Overview
Project Aims
Identify Implement Establish
best practices to develop and implement a clinical and patient
toolkit to guide process improvement work.
the Maternal Care Home (MCH) model to engage/empower
expecting mothers in coordinated care and wrap-around services
including pre-and post-natal care, addiction treatment, counseling, Medication Assisted Treatment (MAT), recovery support, and
care management.
a quality improvement structure involving monthly technical
assistance calls to share and discuss best practices, quarterly clinical learning sessions, and
individual coaching calls.
Develop
a rapid cycle quality improvement feedback process.
Core Elements
MOMS 1.0 Sites
Major Findings from MOMS 1.0
MOMS participants were more likely to receive prenatal care, behavioral health care, & MAT in each trimester of pregnancy than the comparison group.
MOMS participants were 45% more likely to continue to participate in substance abuse treatment 4 to 6 months postpartum.
Maltreatment was 18% lower & out‐of‐home placement was 19% lower among families in the MOMS project than the comparison cohort.
The rate of low birthweight was similar among infants in the MOMS cohort and the Medicaid comparison group.
Mothers who received MAT in the third trimester of pregnancy had infants with a significantly shorter NICU length of stay.
Improving Care
NICU Length of Stay
Treatment Retention
Family Stability
Birthweight
MOMS 2.0 Locations
14
OPQC NAS Project
Ohio Children's Hospital Association NAS Consortium
• September 2012 –September 2014• Six children’s hospitals and their affiliates
(20 total hospitals)• Funded by Office of Governor John Kasich • Goals:
– Understand epidemiology of mothers and infants with NAS by following longitudinal cohort
– Determine the “potentially better practice” for NAS treatment
– Identify variation and areas for future research
Spreading OCHA learnings through Ohio
• 54 sites:– 26 Level III
NICU’s – 26 Level II Special
Care Nurseries– 2 Normal
Newborn Nurseries
• Funded by Ohio Dept. of Medicaid to start January 2014
Attain high reliability in NAS scoring
• All sites use same tool
• Train RN staff to 90% reliability in scoring using D’Apolito Training System
• In Pilot work, we were able to see drop in max score when training completed
• OPQC has sent out DVD/workbook’s to each site
Standardize Pharmacological Treatment Bundle
Initiate Treatment should be initiated if infant has:
• 2 consecutive scores > 8 or• 1 score > 12
Drug: Morphine/ Methadone0.05 mg/kg PO
Escalate If ≥ 12, increase dose
Stabilize No increase for 48 hrs
Wean 10% of max dose dailyDischarge
• 48 hours off Morphine• 72 hours off Methadone
Ohio Potentially Better Protocol
Standardize Non-Pharmacological Treatment Bundle
OPQC Interventions Focused on Attitude Change
• Unit wide training for all NICU staff about living with OUD—”Nurture the Mother-Nurture the Child” video
• Sharing stories of pregnant women with SUD—session with panel of mother of infants with NAS
• Education about addiction as a chronic disease—lectures by addiction specialist
• Community resources outreach—NICU teams identified community resources available to support mother-infant dyad and examined barriers to accessing resources
Partner with other stakeholders to influence policy and primary prevention
All available for download on our website at https://opqc.net
Phase I ResultsAfter 9 months of improvement work, length of treatment decreased by 9% from 13.4 to 12 days …and LOS decreased by 9% from 18.3 to 17 days in
September 2014
Formula Choice based on Orchestrated Testing Results
Overall, the Orchestrated Testing data suggest that use of 22 kcal/oz could be a beneficial practice for NAS non-pharmacologic support
• Consistent benefit of 22 kcal/oz feeds on weight loss, treatment failure, and length of stay– 22 kcal/oz formula is associated with less treatment failure
and shorter length of stay, though only explains a very small amount of the variation
• Benefit of LLF is not consistent across outcome measures--possible synergistic effect with 22 kcal/oz on weight loss and length of stay, but not on treatment failure
Phase II ImprovementWe saw increases in the use of 22 kcal/oz and low lactose feeding
55%
74%
Phase II Improvement (cont’d)Further reductions in LOS were seen with implementation of findings from OT
OT Ends
Prelim Results
ReportedFinal
Results Reported
Phase I Phase II/OT Sustain
Reductions in LOS18.317 days (Phase I)1716.3 days (Phase II)
Total reduction of 2 days!
“MOMS PLUS” FRAMEWORK”
Coordination of Obstetric (OB), Medication Assisted Treatment (MAT)/Opioid Treatment Program (OTP),Behavioral Health (BH) and Neonatal/Pediatric providers to deliver:
• Compassionate and coordinated clinical and community based services• Support for mother/infant dyad post delivery
4 Faculty Mentor Sites
24 Partner Sites
Michele Walsh, MD, MSE Neonatal Clinical LeadRainbow Babies & Children’s - Cleveland
Welcome from OPQC – MOMS Plus Project
Jennifer Terry, MHAProject ManagementOPQC Central
Carole Lannon, MD, MPHQuality Improvement LeadCincinnati Children’s Hospital Medical Center
Rachel Staley, MPAProject ManagementOPQC Central
Heather Kaplan, MD, MSCE Neonatal & QI FacultyCincinnati Children’s Hospital Medical Center
Mike Marcotte, MDOB Faculty, MOMS+ MentorGood Samaritan Tri-Health Cincinnati
Jennifer Bailit, MD, MPHOB Faculty, MOMS+ MentorMetroHealth - Cleveland
Mona Prasad, DO, MPHOB Faculty, MOMS+ MentorOhioHealth Grant - Columbus
Dave McKenna, MDOB Faculty, MOMS+ MentorMiami Valley Hospital - Dayton
Susan Ford MSN, RNState Quality Improvement
ConsultantRainbow Babies & Children’s - Cleveland
Jay Iams, MDObstetrical Clinical LeadProfessor Emeritus - OSU Columbus
Melanie Glover, MDOB Faculty, MOMS+ MentorMiami Valley Hospital - Dayton
OPQC MOMS+ Participating
Sites
NE Region- June 3
Central Region
SW Region- May 30
NW Region- May 23
Dayton Region
Southeast OhioOhioHealth O’Bleness Hospital (Athens)Adena Regional (Ross)Southern Ohio Medical Center (Scioto)
West Central/DaytonMiami Valley Hospital (Montgomery)Atrium Medical Center (Warren) St. Rita’s (Allen)Southview Medical Center (Montgomery)Springfield Regional Hospital (Clark)
Northwest Ohio ProMedica Toledo Hospital (Lucas)Mercy St. Vincent Medical Center (Lucas) Blanchard Valley Hospital (Hancock)
Southwest OhioGood Samaritan (Hamilton) Bethesda North (Hamilton)UC Medical Center (Hamilton)The Christ Hospital (Hamilton)
Northeast OhioMetroHealth Medical Center (Cuyahoga) Akron General AxcessPointe (Summit)Akron Summa (Summit)Fairview Hospital/CCF (Cuyahoga)Hillcrest Hospital/CCF (Cuyahoga)St. Elizabeth Boardman (Mahoning)St. Joseph Warren (Trumbull)University Hospitals Cleveland (Cuyahoga)
Central OhioOhioHealth Grant (Franklin) OhioHealth Riverside Methodist (Franklin)OSU Wexner STEPP (Franklin)Genesis HealthCare System (Muskingum)Lower Lights FQHC (Franklin)Licking Memorial Hospital (Licking)
Southeast Region
Northwest Region
Southwest Region
Northeast Region
IHI Breakthrough Series
SMART Aim
Key Drivers Interventions
By June 30, 2019 we will:Optimize maternity medical home to improve outcomes for pregnant women with opioid use disorder (OUD) as measured by:
• Increased identification of pregnant women with OUD
• Increased % of women with OUD during pregnancy who receive prenatal care (PNC), Medication Assisted Treatment (MAT) and Behavioral Health (BH) counseling each month
• Decreased % of full-term infants with Neonatal Abstinence Syndrome (NAS) requiring pharmacological treatment
• Increased % of babies who go home with mother
Project Leader: Carole Lannon (PI)
Optimize the health and well-being of pregnant women with opioid use
disorder and their infants
Global Aim
Pregnant women withopioid use disorder
Population
Revision Date: 5/21/2018
MOMS+ ProjectKey Driver Diagram (KDD)
Timely identification and tracking of
pregnant women with opioid use disorders
Compassionate and coordinated care
Empowerment of women through
community based services
Supported mother/infant dyad
post delivery
• Complete a standardized screening tool on each patient to accurately identify and diagnose pregnant women with OUD (e.g. 5 P’s, NIDA Quick Screen).
• Establish a coordinated referral system with BH providers, MAT providers, drug courts, prisons, homeless shelters, and ERs.
• Utilize a tracking system (e.g.. Database, spreadsheet) to follow pregnant women with OUD history/diagnosis and all babies with prenatal opiate exposure.
• Check OARRS per prescribing protocols.
• Connect women to vocational training opportunities as applicable• Involve community partners including referrals to faith-based organizations to support
pregnant women with OUD (e.g. support groups, shelters, food pantries, etc.)
• Complete training in trauma informed care and addiction as a chronic illness to provide non-judgmental support for pregnant women with OUD
• Designate a care coordinator to arrange referrals and ongoing communication between the trans-disciplinary care team.
• Provide immediate support/counseling at time of identification by OB/FP by using standardized interviewing techniques.
• Implement a process to prevent acute opiate withdrawal by initiating MAT• Implement a standardized process for referral to appropriate/necessary resources for women
with a positive screen for OUD.• Coordinate care between OB, BH, MAT, NICU/Pediatrics by regularly reviewing shared
patients (e.g. multi-disciplinary care conference, huddle).• Tailor counseling and support for healthy behaviors based on patient-specific situation/need
during pregnancy (sobriety, smoking cessation, stable housing and birth spacing (LARC)), with referral to community resources as needed to augment medical resources.
• Consider implementing or referral to OUD specific Centering Pregnancy© program
• Coordinate Prenatal consultation for pregnant women with OUD with Neonatology/Pediatrics to discuss Neonatal Abstinence Syndrome (NAS)
• Ensure mom and baby have a Patient Centered Medical Home (post-delivery) • Provide a warm handoff to pediatric care provider for infant post discharge (e.g.
call/consultation and newborn/maternal summary)• Provide lactation consultation (if applicable), post partum depression screening and
contraceptive counseling• Prenatal referral for pregnant women with OUD to Community Health Workers and/or home
visitation programs (dependent on region)• Postnatal referral or consideration to Help Me Grow and/or parenting classes• Facilitate continuation and retention of OUD treatment and services during pregnancy and
post-delivery occur (e.g. support of ongoing MAT maintenance services, training care providers to recognize signs of relapse and that mom is continuing in her treatment program)
• Coordinate with Department of Job & Family Services/Child Protective Services regarding reporting requirements and infant plan of safe care
Key Drivers Interventions
MOMS+ ProjectKey Driver Diagram (KDD)
Timely identification and
tracking of pregnant women with opioid use
disorders
• Complete a standardized screening tool on each patient to accurately identify and diagnose pregnant women with OUD (e.g. 5P’s, NIDA Quick Screen).
• Establish a coordinated referral system with BH providers, MAT providers, drug courts, prisons, homeless shelters, and ERs.
• Utilize a tracking system (e.g.. Database, spreadsheet) to follow pregnant women with OUD history/diagnosis and all babies with prenatal opiate exposure.
• Check OARRS per prescribing protocols.
Key Drivers Interventions
MOMS+ ProjectKey Driver Diagram (KDD)
Compassionate and coordinated
care
• Complete training in trauma informed care and addiction as a chronic illness to provide non-judgmental support for pregnant women with OUD.
• Designate a care coordinator to arrange referrals and ongoing communication between the trans-disciplinary care team.
• Provide immediate support/counseling at time of identification by OB/FP by using standardized interviewing techniques.
• Implement a process to prevent acute opiate withdrawal by initiating MAT.
• Implement a standardized process for referral to appropriate/necessary resources for women with a positive screen for OUD.
• Coordinate care between OB, BH, MAT, NICU/Pediatrics by regularly reviewing shared patients (e.g. multi-disciplinary care conference, huddle).
• Tailor counseling and support for healthy behaviors based on patient-specific situation/need during pregnancy (sobriety, smoking cessation, stable housing and birth spacing (LARC)), with referral to community resources as needed to augment medical resources.
• Consider implementing or referral to OUD specific Centering Pregnancy© program
Key Drivers Interventions
MOMS+ ProjectKey Driver Diagram (KDD)
• Connect women to vocational training opportunities as applicable.
• Involve community partners including referrals to faith-based organizations to support pregnant women with OUD (e.g. support groups, shelters, food pantries, etc.)
Empowerment of women through
community based services
Key Drivers Interventions
MOMS+ ProjectKey Driver Diagram (KDD)
Supported mother/infant
dyad post delivery
• Coordinate Prenatal consultation for pregnant women with OUD with Neonatology/Pediatrics to discuss Neonatal Abstinence Syndrome (NAS).
• Ensure mom and baby have a Patient Centered Medical Home (post-delivery).
•• Provide a warm handoff to pediatric care provider for infant
post discharge (e.g. call/consultation and newborn/maternal summary).
• Provide lactation consultation (if applicable), post partum depression screening and contraceptive counseling.
• Prenatal referral for pregnant women with OUD to Community Health Workers and/or home visitation programs (dependent on region).
• Postnatal referral or consideration to Help Me Grow and/or parenting classes.
By June 30, 2019, we will: Optimize maternity medical home to improve outcomes for pregnant women with opioid use disorder(OUD) as measured by:
• Increased identification of pregnant women with OUD
• Increased % of women with OUD during pregnancy who receive prenatal care (PNC), Medication Assisted Treatment (MAT) and Behavioral Health (BH) counseling each month
• Decreased % of full-term infants with Neonatal Abstinence Syndrome (NAS) requiring pharmacological treatment
• Increased % of babies who go home with mother
OPQC MOMS+ AIM Statement
Managed Care Plan Contactseach plan has an identified contact person per region
Health Plan:
AetnaBuckeye
CareSourceMolina
ParamountUnited
• 28 different sites; lots of variability across the state
• “Steal shamelessly –Share seamlessly”
• Collaborative methods –“All Teach, All Learn”
Starting at the beginning
Care Coordination for MOMS Plus Teams
28
May-June 2018Kick off six
regional meetings
Oct AP Call:Screening Tools
for OUD
Sept AP Call:Initial
encounter management Aug AP Call:
Collaboration with MCP/use of PRAF 2.0
July AP Call:Regional
collaboration
February AP Call:MAT for the
Pregnant Patient with OUD
January 2019: Data entry opens
for teams with submitted DUA/BAA !
November Learning
Session in Columbus
March AP Call: Monitoring tools
to support care of the pregnant
patient with OUD
Dec AP Call:Post partum
Pain Management
Jan AP Call:Hepatitis C Screening,
Diagnosis and Management
April AP Call:Testing a
Checklist for Care of the Pregnant Pt
with OUD
May & June 2019 –Regional Meetings across the state!
Start here
CHC Model of Care
Questions??
It takes a village…
The MOMS+ Project is funded by the Medicaid Technical Assistance and Policy Program (MEDTAPP) and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in this meeting are solely those of the authors and do not represent the views of state or federal Medicaid programs.
