A MULTI-INSTITUTIONAL APPROACH TO IMPROVING MATERNAL & FETAL HEALTH

Christie Webster, RNEC, OSFHT

Dr. Hazel Lynn, MD, GBHU

Dr. May Elhajj, MD, GBHS

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CFPC Conflict of Interest

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Presenter Disclosure Presenter: Christie Webster Relationships with commercial interests:

• Grants/Research Support: None • Speakers Bureau/Honoraria: None • Consulting Fees: None • Other: None

EXECUTIVE TRAINING FOR RESEARCH APPLICATION (EXTRA)

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• Program offered by Canadian Foundation for Healthcare Improvement

• Vision: To build leaders in utilizing evidence to guide policy development & decision making in healthcare

• 14 month fellowship: team based • Intervention project

• To engage team in a change strategy • To utilize research based evidence • To focus on a specific issue

The Starting Point: Optimizing Maternal Fetal Health

Planned Pregnancy

Optimal Weight Gain

in Pregnancy

Eliminate Antenatal Smoking

Early Intervention

with Postpartum Depression

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Anecdote

Proportion of women who smoked cigarettes during pregnancy, by Public Health Unit, South West Region, 2008

Data source: Better Outcomes Registry and Network (BORN) Ontario 2008

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Rates of smoking during pregnancy increased with decreasing maternal age – 44.8% of mothers under

the age of 20 smoked during pregnancy, South West Region of Ontario

BORN, 2008

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Context: Smoking Cessation

Services a population of 160,000; mandated to address the issue of smoking cessation related to population health with $350,000 of budget provided by smoke free Ontario program

Services 32,000 patients; trained clinical pharmacist & RN in smoking cessation counseling. Participating in Smoking Treatment for Ontario patients (STOP) program

Includes 6 hospitals that provide acute health care to Grey Bruce area. Owen Sound hospital is the only site that provides obstetrical care. Smoking cessation identified as a priority in strategic plan

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Critical Summary of Evidence

ACOG and SOGC strongly endorse obstetricians being involved in smoking cessation programs

Economic evaluations of smoking cessation and relapse prevention programs for pregnant women: a systematic review. Ruger, et al. Value Health. 2008 Mar-Apr;11(2):180-90.

For every dollar invested in smoking cessation programs, $3 are saved in downstream health-related costs.

Interventions for promoting smoking cessation during pregnancy. Lumley J. et al. Cochrane Database of Systematic Reviews, 3, 2009.

Positive impact as far as pregnancy and fetus - less risk of complications

Neonatal care for infants born to smoking mothers: extra $700.

Adams et al: Health Econ 2002

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Critical Summary of Evidence – cont’d

EMRs-potentially valuable component to support smoking cessation

Boyle R, Solberg L, Fiore M. Cochrane Database System Rev. 2011 Dec 7;(12):CD008743.

An office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral has been proved to increase quit rates.

Obstet Gynecol. 2010 Nov;116(5):1241-4

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Change Management Process: The Constellation Model (Surman, T&M, 2008)

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Need & Opportunity

Extra team: Vision & Plan

Constellations: Self

organizing action teams

Enabling Factors

Foundational agreement-EXTRA program No cost (our time) Collaborative partnerships Shared vision Feedback loops (stats, PHC providers, HCPs) Simple tools applied in practice

EMR Smoking status reminder EMR message for smoking cessation counseling Highlighted section in antenatal record#1

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Smoking history is highlighted – if “yes” –refer for smoking cessation counseling

Barriers

Communication challenges Large geographic area of Grey Bruce Multiple HCPs with varying levels of

administrative support HCPs who lack skill in with dealing with a

younger population High rate of “No Show/No Response” to

smoking cessation counseling

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Results: Provider Initiated Referrals to Smoking Cessation Counseling

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TIME FRAME IDENTIFIED ANTENATAL SMOKERS ON EMR

# PROVIDER INITIATED REFERRALS

# NO SHOW &/OR NO RESPONSE

2010 0

2011 2

Jan - Aug 2012 ** 30 2 (6.7%)

Sept 2012 – Jan 2013

43 16 (37.2%) 7

Feb – March 2013 6 1 (16.7%)

April – Dec 2013 28 14 (50%) 8

Jan – April 2014 29 13 (44.8%) 4

**Pre EXTRA IP

Organizational Impact

Increased uptake of an available resource within an organization (smoking cessation counseling)

Heightened awareness of the problem Workshop “A Woman-Centered Approach to Tobacco Use &

Pregnancy”-June 2013 (GBHU)

Momentum for other organizations – role model Collaborative partnerships—beyond the project

Breaking down the silos

Focus on a Modifiable risk factor – smoking cessation Reduce duplication of work between institutions Health Links—identification of factors that make

pregnancy more expensive…reduce risk!

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Smoking During Pregnancy

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0

5

10

15

20

25

30

2006 2007 2008 2009 2010 2011 2012

Perc

ent

Year

GBHU Ontario

17.2

10.7

Data Source: BORN Ontario, 2006–2012

Sustainability

Feedback to MDs, HCPs (referral rates)- accountability No structural reorganization; no redesigning patterns of

delivery of care Patient focused - developed around the woman’s

preconception/pregnancy journey

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Next Steps 19

Partnership with Keystone Child, Youth & Family Services, host to Healthy Beginnings (CPNC) sessions for teenage pregnant families Fall 2014 “lunch & learn” joint pilot project by OSFHT clinical pharmacist to

address stress mgmt & smoking cessation with interested clients (with or without partners); captive audience with food, transportation provided

3 sessions/year planned

Smoking cessation “swag” donated by GBHU

Host site application submitted to RNAO Best Practice Champions for Smoke-Free Pregnancies Workshop

If accepted, to be offered to OSFHT and community partners

Electronic pre/postnatal resource document-developing (OSFHT) Plan to educate HCPs on this resource

Questions? 20