Improving Birth Outcomes

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DISCLOSURE

• I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

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The Role of the Leader

“Servants of what is.”And,

“Shapers of what might be.”

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Leading is not Tidy

• Decisions are made and then reversed• Misunderstandings are frequent• Inconsistency is inevitable• Inside every solution are the needs of new problems• Most of the time most things are out of hand

Nonaka and Takeuchi, The Wise Leader

Health and Mortality

Will Changes in Models Force Changes in Structure and Systems?

Structure Process Outcomes

Improvement Science

Hoffer-Gittlell, Heller SchoolBrandeis University

Viab

ility

Where are you in the Model Life Cycle?

ModelsAdapted from The Second Curve, Ian Morrison 1996

Clinical Model Episodic Care Coordinated Care Patient Directed Care

Business Model Fee for Service Bundled Payment/Capitation Disruptive Innovation?

Infrastructure Segmented Integrated Cloud

Adaptive Leadership

TechnicalLeadership

Patient

Inflection Point

The Patient’s Health RecordCloud Infrastructure

Fitness Center

Home Telemetry

Pharmacy

Financial Services

Grocery Store

Hospitals

Primary Care

Home Health Care

Long Term Care Specialist

Elective Deliveries <39 Weeks Intermountain Healthcare

0%

5%

10%

15%

20%

25%

30%

35%

Month

Per

cen

t <

39 W

eeks

What is:

Elective Deliveries <39 Weeks Intermountain Healthcare

0%

5%

10%

15%

20%

25%

30%

35%

Month

Per

cen

t <

39 W

eeks

And what can be:

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Opportunities

• Each week 174 babies premature• VLBW babies in South Carolina= $107 million per year.• Over a thousand VLBW births per year • 235 VLBW cases are multiple birth deliveries • Small number but over 50% of hospital charges

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Louisiana Birth Outcomes Initiative

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Louisiana Philosophy

We strive to improve health and health care by:

– Using the “Lifecourse” theory– Motivating and building will for change with hope and

optimism– Consensus, consensus, consensus

Louisiana Rankings

Indicator US Louisiana Rank

Preterm birth (< 37 weeks gestation, %) 12.3 15.4 48th

Low Birth Weight (< 2,500 grams, %) 8.2 10.8 49th

Very Low Birth Weight (< 1,500 grams, %) 1.5 2.1 48th

C-section rate (%) 32.3 38.0 49th

Infant Mortality (<1 year old, per 1000 live births)

6.75 9.17 46th

Source: Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data for 2008. National vital statistics reports; vol 59 no 1. Hyattsville, MD: National Center for Health Statistics. 2010.

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Interventions to Improve Birth Outcomes

Increase use of

smoking cessation treatment

Increase use of

17P

Reduce preterm & repeat C-section

New indicators

for hospital quality

monitoring Risk assessment

and care plan for

women with adverse outcome

Infant

Chronic disease

management

Screening and treatment for behavioral

health

Early and Adequate Prenatal

Care

Home Visitation (Healthy

Start, NFP)

Intensive care

coordination/case

management

FIMR

Family planning

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Top Down

• Tony Keck• Louisiana Department of Health and Hospitals• Louisiana Perinatal Commission

– Authorized in 2006, 16 member commission appointed by Governor Jindal

• Blue Ribbon Panel

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Bottom Up

Birth Outcomes State Wide Action Teams • Five action teams which represent community partners,

consumers, advocates, public health professionals, clinicians, hospital administrators, and insurers

» Care Coordination» Health Disparities» Patient Safety and Quality» Behavioral Health» Data and Measurement

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Ideas

"Ideas are like rabbits. You get a couple and learn how to handle them, and pretty soon you have a dozen."

-- John Steinbeck

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Birth Outcomes Priorities

• Increase Data Capacity and Performance Measurement

• Institute statewide comprehensive Behavioral Health screening

and brief intervention for pregnant women in Medicaid

• Pilot and expand access to Interconception Care Coordination

• Increase Patient Safety and Quality of Care

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Patient Safety and Quality of Care

To create a culture of continuous quality improvement and safety in

Louisiana’s birthing hospitals.

Gestational Age That Women Consider it Safe to Deliver

Rise in Induction of Labor in US 1990-2006

Complication Rates, Scheduled Repeat Cesareans by Weeks of Gestation

PERFORMANCE

Indi

vidu

al A

uton

omy

Guidelines as defined by professional standards Legal space

Usual spaceof action

Illegal-normalspace

the ‘illegal-illegal’ space (for almost all of us!)

VE

RY

UN

SA

FE

SP

AC

E IndividualPressures

PerceivedVulnerability

Belief inSystems-guidelines

<1% 5% 50% 80% 100% percent of staff

Safety regs & good practices

Certification/ accreditation

standards

Collective memory of experiences

Forbiddenbehavior except under extreme circumstances

Forbiddenby all

55 55 in a in a 5555

75 75 in a in a 5555

95 95 in a in a 5555

115 115 in a in a 5555

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Progress!

39 week initiative begins

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Data and Measurement

Create transparency, accountability and quality improvement infrastructure for perinatal quality improvement measurement and reporting.

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Perinatal Quality Scores

• Pre-term births• VLBW by level NICU • Nulliparous term singleton vertex C-sections (NTSV)• Elective deliveries < 39 weeks gestation

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Behavioral Health

Ensure that all women in Medicaid receive a behavioral health screen, brief intervention referral and treatment for substance use,

depression and violence

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Care Coordination

To provide care coordination for every woman in Louisiana Medicaid who has had an adverse pregnancy outcome

HealthDevelopment

EducationalDevelopment

CommunityDevelopment

Economic Development

Best BabiesZone

Viab

ility

Where are you in the Model Life Cycle?

ModelsAdapted from The Second Curve, Ian Morrison 1996

Clinical Model Episodic Care Coordinated Care Patient Directed Care

Business Model Fee for Service Bundled Payment/Capitation Disruptive Innovation?

Infrastructure Segmented Integrated Cloud

Adaptive Leadership

TechnicalLeadership

Patient

Inflection Point

40

Department of Health and Hospitals

Louisiana Birth Outcomes Initiative

DHH Bienville Building

628 N. 4th Street

Baton Rouge, Louisiana

(225) 342.9500

Website: www.dhh.la.gov

The Birth Outcomes Initiative

Rebekah Gee, MD, MPH, MS, FACOG

Director of Birth Outcomes

Michelle M Alletto, MPA

Deputy Director

Bruce Greenstein, Secretary

Kathy Kliebert, Deputy Secretary

Jerry Phillips, Undersecretary

This document was published in-house by the DHH Office of Birth Outcomes