A14.1 Multi Institutional Approach_Christie Webster

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 2

Presenter Disclosure Presenter: Christie Webster Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None 

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EXECUTIVE TRAINING FOR RESEARCH APPLICATION (EXTRA) 3

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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

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The Starting Point: Optimizing Maternal Fetal Health Optimal Weight Gain in Pregnancy

Planned Pregnancy

Eliminate Antenatal Smoking

Early Intervention with Postpartum Depression

Anecdote 5

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

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 7

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

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

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

Critical Summary of Evidence 8 

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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 MarApr;11(2):180-90.

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

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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

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

Adams et al: Health Econ 2002

Critical Summary of Evidence – cont’d 9 

EMRs-potentially valuable component to support smoking cessation Boyle R, Solberg L, Fiore M. Cochrane Database System Rev. 2011 Dec 7;(12):CD008743.

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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)

Need & Opportunity

Constellations: Self organizing action teams

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Extra team: Vision & Plan

Enabling Factors 12

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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

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

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Barriers 14

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 TIME FRAME

IDENTIFIED # PROVIDER ANTENATAL INITIATED SMOKERS ON EMR REFERRALS

2010

0

2011

2

# NO SHOW &/OR NO RESPONSE

Jan - Aug 2012 **

30

Sept 2012 – Jan 2013

43

Feb – March 2013

6

1 (16.7%)

April – Dec 2013

28

14 (50%)

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Jan – April 2014

29

13 (44.8%)

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**Pre EXTRA IP

2 (6.7%) 16 (37.2%)

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Organizational Impact 16

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Increased uptake of an available resource within an organization (smoking cessation counseling) Heightened awareness of the problem 

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

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Workshop “A Woman-Centered Approach to Tobacco Use & Pregnancy”-June 2013 (GBHU)

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!

Smoking During Pregnancy 17 30

25

20

Percent

17.2 15

10.7 10

5

0

2006

2007

2008

2009 Year GBHU

Data Source: BORN Ontario, 2006–2012

Ontario

2010

2011

2012

Sustainability 18

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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

Next Steps 19

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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

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3 sessions/year planned

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Smoking cessation “swag” donated by GBHU

Host site application submitted to RNAO 

Best Practice Champions for Smoke-Free Pregnancies Workshop

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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?

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