Team Based Care in the Family Planning Setting

Susan Kendig, JD, WHNP-BC, FAANPTeaching Professor; Coordinator, Women’s Health

Emphasis AreaUniversity of Missouri-St. Louis

Director of Policy, National Association of Nurse Practitioners in Women’s Health

Disclosures

Susan Kendig, JD, WHNP-BC, FAANP

Commercial Interest Role Status

Nothing to disclose

Objectives

• Define core concepts of collaboration and team-based care as it applies to the family planning setting;

• Discuss the six core principles that support successful implementation of team-based care

Collaboration in Practice: Implementing Team-Based Care

Goal: Introduce ACOG’s “Collaboration in Practice: Implementing Team-Based Care”

Objectives: • Define core concepts of collaboration and team-

based care as it applies to the family planning setting;

• Discuss the six core principles that support successful implementation of team-based care;

Background Information• Response to demand for coordinated, value-driven care

models in the face of HCP shortages and shrinking resources;

• John Jennings, ACOG’s 2014 President, chose revision of ACOG’s Guidelines for Implementing Collaborative Practice (1995) as the priority issue during his presidential year;

• Convened interdisciplinary task force representing physicians, NPs, midwives, PAs, consumers, clinical pharmacists;

• Resulting document endorsed/supported by 21 national organizations thus far.

Why Team-Based care?Typical Medicare Beneficiary• Visits annually:

– Two primary care providers– Five specialists– Other health care providers in

diagnostics, pharmacy, other services

• More visits if multiple chronic conditions

• Discontinuity impedes care, decreases safety, increases cost. Bodenheimer, T. (2008). NEJM, 358, 1064-67; IOM. (2001). Crossing the Quality Chasm.

Women’s Reproductive Health• 45% of U.S. pregnancies

unintended– 42% result in AB– 68% paid for by public

insurance programs • Total U.S. Government

expenditures ~$2.1 billion annually (Guttmacher Institute (Feb. 2015). Public Health Costs from Unintended Pregnancy)

• Effectively planning for pregnancy, entering pregnancy in good health, and being fully informed about reproductive and general health improves birth outcomes (IOM, 1985)

Defining Team-Based CareTeam-Based Care – Provision of health services to individuals, families, and/or communities by at least two health care providers who work collaboratively with patients and their families – to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high quality care.Collaboration – Process involving mutually beneficial active participation between autonomous individuals whose relationships are governed by negotiated shared norms and visions.

Quality Family Planning ServicesFamily Planning: Contraceptive, pregnancy testing/counseling,

assistance to achieve pregnancy, basic infertility, STD/HIV/AIDs, and other preconception health services;

Related Preventive Services: Services considered beneficial to reproductive health, closely linked to family planning services, and appropriate to deliver in the context of a family planning visit but that do not contribute directly to achieving or preventing pregnancy (e.g., breast and cervical cancer screening).

Other Preventive Health Services: Services important to primary care, but no direct link to family planning (e.g., lipid, osteoporosis, skin cancer screening)

Gavin, L, Moskosky, S., Carter, M, et al. (2014). MMWR, 63(RR04);1-29

The Women’s Health team

Women’s health team

Primary Care /Specialty

OB/GYN

Family Planning/QFP

Continuum of Women’s Health Care:“Team-based care provides an integrated process over the course of not just a specific or singular experience, but across a patient’s lifespan…” (Task Force on Collaborative Practice, 2016.)

l

Preconception

Prenatal

Intrapartum

Postpartum

Interconception

Post Reproduction

Another View: Virtual Women’s Health Team

Women’s Health Team

QFP/FP/OB-GYNPrimary Care

Specialty Care

Guiding Principles

Patient- Family Centric• ACOG: Patients and families are central to/actively engaged as

members of the health care team– Focus on Patient health needs – Respect patient values, preferences, goals– Patient is a partner in managing health and decision-making

• QFP: Client-centered approach– Client's primary purpose for visiting the service site must be

respected– Provide and maintain confidential services– Broad range of contraceptive methods available to meet individual

client needs and preferences– Organizational policies, governance, and provider attitudes and

practices support delivery of services in a culturally competent manner so as to meet the needs of all clients.

Shared Vision• ACOG: Team has a shared vision

– Integrated body of knowledge and skills that works together toward common goals

– Embraces patient expertise, perspectives, priorities, needs

– Identify goals that all team members, including patient, agree on.

• QFP: Underpinning of recommendations is that improving the quality of family planning services will lead to improved reproductive health outcomes.

Role Clarity• ACOG: Role clarity is essential to optimal team building and

team functioning– Each member recognized for his/her expertise– Team focus is on meeting patient needs while maximizing

expertise of providers on the team• QFP: Accessibility

– Remove barriers to contraceptive use, – Family planning visit provides access to a broader range of

primary care and behavioral health services, – Create and strengthen links to other sources of care.– Exemplar: Standardized tiered counseling by trained non-

clinicians; shared contraceptive decision-making between patient and provider; method prescribed/placed. (Madden, T. (2012) Contraception)

Accountability• ACOG: All team members are accountable for

their own practice and to the team– Practice to the best of abilities– Consistently act in best interest of patient considering

cost, quality, timeliness of care– Accept responsibilities within scope of practice and

experience– Integrate profession specific recommendations with

other team members recommendations for care– Maintain education necessary for licensure and

credentialing.

Accountability• QFP: Strong QI component

– Safety. Integrate MEC, CDC and USPSTF recommendations on STD, preconception, related preventive health services.

– Effectiveness. Support offering a full range of FDA–approved methods, and appropriate counseling, highlights effectiveness of specific clinical preventive health services and identifies clinical preventive health services for which the potential harms outweigh the benefits.

– Timeliness. Ensure services provided in a timely manner.– Efficiency. Identify core set of services providers can focus

on delivering, and ways to maximize the use of resources.– Value. Highlight services shown to be very cost-effective

Effective Communication• ACOG: Effective communication is key to quality

teams– Opportunity to relay important information about

team tasks– Evidence of team’s interprofessional nature– Enables continuous learning environment; translates

to better, more efficient care• QFP: Provision of family planning and related

services requires communication among internal team as well as external (virtual) team members

Team Leadership• ACOG: Team leadership is situational/dynamic

– Team member who can best address patient priority needs assumes lead provider role.

– One type of training or perspective not felt to be uniformly superior to others

• QFP: – Consistent use of provider neutral language– Successful models incorporate non-clinicians and

clinicians to achieve high quality, safe and efficient practice.

Continuum of Women’s Health Care:Fluid Team Leadership

PreconceptionFP provider PCPWH providerPediatrician

PrenatalOB Provider

IntrapartumOB ProviderHospitalist

PostpartumOB ProviderPCPFP ProviderNo one?

InterconceptionFP ProviderWH ProviderPCPNo one?

Post ReproductionFP ProviderWH providerPCP Specialist

Implementation of Team-Based, Integrated Care in the Family Planning Setting

• Telehealth, use of technology to deliver clinical services, can be considered as a non-traditional method for delivering team-based care, especially when access is limited.– Diagnostic test interpretation– Patient counseling – Disease management/health promotion

• Connectivity via health information exchange (HIE)

Other Considerations• Scope of practice and licensure laws and

requirements are not uniform across states. • Payment challenges may be internal (RVUs,

incentives) or external (payer or licensure implications)

• Multiple opportunities for change.

Where Does the Family Planning Provider Fit In?

Contact InformationSusan Kendig, JD, MSN, WHNP-BC, FAANP

Teaching Professor; WHNP Emphasis Area Coordinator, University of Missouri- St. LouisDirector of Policy, National Association of Nurse Practitioners in Women’s Health (NPWH)314-629-2372; suekendig@gmail.com

Access “Collaboration in Practice: Implementing Team-Based Care” at http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Collaboration-in-Practice-Implementing-Team-Based-Care

Access the Executive Summary at http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Executive-Summary-for-Collaboration-in-Practice-Implementing-Team-Based-Care