AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
RIMA JOLIVET: Hi, everybody. Well, I'm the opening act. My job is to warm you guys up and set the stage for Chan and Jane. They're going to be talking about their site‑specific experiences implementing centering. So just to kind of lay the foundation for that, I wanted to talk a little bit about the centering model so you have a sense of what the basis is and what it hopes to achieve and how it's done.
Then my hope is that I'll also get a chance to talk a little bit about how it was developed and end up speaking about some of the published studies, primarily a large study that was recently published last November and some of the ongoing research and things that are happening with centering now. And then I'll turn it over.
So basically centering pregnancy is a change in the paradigm of prenatal care. What it hopes to do is bring women out of the individual exam room into a group setting to receive their care.
And Sharon Rising, the author of this program, designed it really as a survival, as a survival mechanism for herself, because it's very difficult as we all know in providing maternal and child health to continue to serve in a system that's really broken. And so one of her big inspirations is from Don Barrack, who you probably know from the Institute of Healthcare Improvement , and this is just an opening thought to start this session off and also gives you an out, if you want to get out of the room. Nobody should be in this room if you think it's fine. We have a gap between where we are and where we could be. The first step has to be owning the problem. So that was the problem that Sharon was faced with on a daily basis and being very frustrated with on a daily basis, and trying to think about, okay, how can I continue to keep my heart and soul in this, provide good care and not burn out?
The Institute of Medicine in its seminal report Crossing The Quality Chasm, which I'm sure you're familiar with, starts talking about six aims for healthcare in general, and the aims are so basic as to be, frankly, almost pathetic at this day and age that we have to say well we want healthcare to be safe. But we know that healthcare isn't safe and that patients are injured in great numbers every year. It should be effective. We want to be providing services that are based on knowledge and services that are likely to benefit the people who are receiving them. So that includes refraining from providing services to people who aren't likely to benefit.
We want our care to be patient‑centered. And when I'm reading these, I'd like you to think about traditional prenatal care, where you're probably running around a clinic popping your head into office after office and spending a very inadequate amount of time with people and trying to provide this kind of care. Care that's respectful and responsive to individual preferences and needs. And letting the clients' values guide the kind of care we give. Really our medical culture is such that most of our care is centered around the needs and convenience of institutions and so rarely around the needs of patients.
And we want care to be timely. You know, how many times do people have to sit and wait in the waiting room to get their care provided? And not only that, as a care provider, how many times are you stuck waiting for the chart to come, waiting for the person to come back from the screening room, waiting for the person to get through billing. All of these inefficiencies make care very frustrating and reduce the quality of care.
Efficient. We want care that avoids waste of supplies and equipment, but also how would it be if in our care settings, people said, wow, that's such a wonderful idea, let's not waste that; let's really put that to use? And I think so often we're running around putting out brush fires, that our talents and energy are wasted. And we know that care is inequitable. And we'll talk some more about that and how centering addresses that.
So I want to start, before getting into the model, talk a little bit more about another document, Caring for our Future, which, as you know, is the report from the Public Health Service Expert Panel. It came out in 1989. It was looking at, you know, how much of the prenatal care that we provide is evidence‑based, and really what it showed was that almost nothing is. And so much of what we do is based on tradition, convenience and it's not really visionary. It's not aimed at providing care that is based in evidence.
So caring for our future had some objectives for prenatal care for pregnant women, for fetuses and infants and families. As I go through them quickly again, I'd like you to imagine yourself in the clinic settings that you're familiar with, trying to meet these goals for prenatal care within the model as it exists now.
So for the pregnant woman: Increased well‑being, improved self‑image, decreased maternity and morbidity. We're very concerned about outcomes. Self‑care skills, development of parenting skills. Honestly, are we really able to address those kinds of issues in the way that we would like in a ten minute visit? For the fetus and infant, we're very concerned about reducing preterm birth and growth restriction, congenital anomalies and failure to thrive. And the lunchtime speaker, Jennifer House, did a nice job setting us up because I'll be talking a little bit about the impact centering can have on these very important concerns.
We want our care to be appropriate, and we'd like to ‑‑ we'd like to provide for ongoing health promotion for these infants, in terms of developmental assessment, immunizations and regular health supervision. Again, these are very tall orders given the circumstances in which we work.
For the family, I think this is really one of the arenas in which our care is the most efficient. Promoting healthy family development. Reducing family violence. I mean, in the traditional model of prenatal care how do we address this? In truth is we hardly can. Promoting appropriate use of community resources. I'll talk about the model of centering pregnancy and then I'll go through some examples, and at the end I'll start to talk a little bit about research.
Basically centering pregnancy combines in a group setting the three components, ideally, of prenatal care: The assessment, which is what we think of when we think of prenatal care. That's really the checkup. I can remember as a consumer in the healthcare system coming in, waiting for an hour and a half to pee in a cup and get my blood pressure taken. And that's it? So that's the part that we think of as prenatal care most of the time. Education, which some people get separately and some people don't get at all, or some people get piecemeal in little bits and pieces as they can. And support, which is really an important aspect of care for women who are pregnant, particularly.
So just very quickly we can go down and look at some of the characteristics of traditional prenatal care and how they compare to some of the characteristics of group care. Group care is a new way of doing things, so it's thinking outside of the traditional box. And traditional care: We're in an exam space, but this is moving care into a group space. So what happens when we do that, quite a few things. One of the things I've touched on before is that in traditional care it's very repetitive. So that's inefficient and it's particularly difficult for providers to try to provide the same kind of individual teaching in a repetitive way without burning out. Group teaching is richer. Because of the time constraints, education tends to be very random. And we pick what we think people need to know, and that may not be what they actually want to know or need to know. There's little social contact. In a group there's chance for lots of social contact.
As I've said earlier, I think the traditional model is really centered around, I mean some of us providers would argue with this, but it's provider centered and institution centered as opposed to consumer centered and the approach is very narrow. It's really risk assessment as opposed to a more holistic assessment of the whole family system, the woman is a person and her growing baby.
So in the traditional model, we focus on the physician or the midwife as the provider of care. But in group care it's really a contract between the practitioner and the woman. And she really participates actively in her care, and that's really a different quality I think in the way care is provided. In the traditional model we're looking at medical outcomes. But group care focuses on empowerment and health empowerment. So it's a wider, richer focus.
Traditional care can be efficient if it's limited but you need to focus it in order to be efficient. That's why you're running back and forth all clinic long.
In this model, when you group people together, there's you know it's just more efficient in terms of the transfer of information. Often traditional care is disappointing to consumers. It just doesn't feel like you're getting very much out of it. Whereas this is empowering to consumers and it's very much fun and energizing both for people who are providing care in this way and for people who are receiving care in this way.
So why groups? Groups are becoming, it's really an idea that's spreading throughout healthcare. But in pregnancy, particularly, I think women, it's a time when women have a great need for affiliation, and so it really honors that need. It's a very efficient conduit for information. We talked about that. And it encourages people to be actively participating in their healthcare, which is something that I think we all strive to do, and so oftentimes we're talking to people and they're kind of going yeah, yeah, yeah. And there's this blankness behind their eyes and you're thinking boy is this making any difference at all. Whereas this is very energizing and people become involved. It's so much more powerful when we learn from each other than to have, and this is a very noncentering way to be talking about centering up here in front of you lecturing. It's so much more powerful when participants learn from each other.
And so many people in our society are bereft of community, and particularly during pregnancy, is a time when there's a great need for affiliation and for support. So this is really a efficient way to build community. And when women get together in groups, they build a vehicle for social change.
So we think that groups are efficient for the healthcare system, and I'll talk a little bit more. That's a great question that many people have about the cost‑effectiveness of this model. But what we can say is it certainly seems to be an efficient way to provide care, and that that's complex when you think about it. If you gather women together in a room and provide their care, first of all for your system you have a lot of free rooms, and you have free providers as well. So we can talk some more about that.
But not to be, I think not to be denigraded as one of the important parts, this is a fun and interesting way for women and for providers to work together to provide healthcare.
Claire Westall is one of the investigators on the study, the NIH‑funded study out of Yale and Emery. She's down at Emery. And this is one of the quotes she said: "In truth I continue to be awed by the power of the group. We're having such a good time and such laughs. I'm learning that it doesn't matter what we don't talk about because we're talking about what matters to the group."
And I think that's really important. So many times in individual care we pick what we think people need to know but we really don't know our clients very well. And sometimes I think that this is particularly pertinent, sometimes, in groups where we're trying to, we're trying to offer culturally competent care, when we don't really understand the cultures in which we're working. So here's a picture, just for fun. People and their babies coming back for a reunion. So I'm going to talk a little bit about what makes centering centering. There are ten essential elements. Outside of those ten elements there's a lot of room for creativity. Again, this is a fun and creative model. So anything that's not in the ten elements is something that you know you can tailor to your system and tailor to your population, but things that are essential elements are essential elements because we worked with them for a long time. We realized through trial and error when these things aren't in place it's just not quite the same.
First of all, the assessment occurs within when the group space. And this is something that's a leap for a lot of people. That means that the belly check, the fundal height, the heart tones, all that happens within the group space. It doesn't work to take women out of the room to do that and then come back in for a discussion. I think partially what that's saying is that this isn't something that's appropriate for the group. And that changes the dynamics.
So it's very powerful to have that assessment happen in the group space. And women are involved in their self‑care activities. And this is really important. It's like when you're in the passenger seat you don't realize how you're getting somewhere. When you take your own blood pressure you start to understand what it means and you become interested in it and you start to take responsibility for it. So that's an essential element.
Sharon and I talk a lot about this. I think the first two items are kind of like the skeleton or the body of centering. But the soul of centering is the facilitative leadership style. That's a very big conceptual leap as well. We're taught in healthcare that we have so much expertise. We have all these degrees, all this knowledge, all this stuff that we want to impart, and we feel like that's our mandate. But in centering, really, we need to step back, close our mouths and learn from women and see what it is that they're interested in. So that takes a lot of unlearning, and that's something that we spend a lot of time in the training sessions for centering.
Each session has an overall plan. So there is kind of a curriculum, and I'll go through it a little bit more. But it's flexible. Attention is given to the core content, but emphasis may vary. That's related to the previous bullet. A good example for that, if you have a woman of 12 women and none of them smoke, why would you spend half an hour smoking cessation. That would be the ideal group. That's the kind of thing, but it's really flexibility to tailor the content to the values and the needs of the women who are in the group.
There's stability of group leadership, and this is really important, because groups develop history and they develop trust. And so it's really important that the two people who own the group really take that ownership seriously.
Group conduct honors the contribution of every member. This is a very democratic model. And it's not for nothing that it's conducted in a circle. So that really everybody is honored and that means that their silence is honored, too. That's sometimes people will ask questions about HIPAA and that's one of the answers to those questions that nobody is forced to be there, nobody is forced to contribute; you share what you want to because you feel you're in a safe place to do that.
And the group is conducted in a circle. So I already jumped ahead. Composition of the group is stable but not rigid. That speaks to the fact that, first of all, we are building history and trust, so you don't want it to be different people each time, but women are very welcoming of other women. If you have somebody who comes in late to care and she would fit in with the group, women will welcome her, and in fact you know that's a very nice way, if you are late to care, to be embraced by a group and get some support.
Group size is optimal. So you know an optimal size is not too small so that people feel uncomfortable that the spotlight is on them the whole time, but big enough to be efficient. We think that eight to 12 women is the optimal size. And, you know, taking into account that they'll bring partners often. And so that's probably the best size. It's really important for opportunity, for people to have the opportunity to socialize. And so oftentimes that means providing some food and some breaks in the structure, which are kind of built into the model, so that people have a chance to kind of coalesce and find out about each other and form bonds.
And we really think that it's so important to continue to engage in outcome evaluation to see how the model is working, and again I'm going to talk a little bit about some of the studies that are ongoing, some that have been published. But for every site that implements centering, there is an evaluation, the model includes evaluative tools.
Okay. So the design. What happens is that women come in for their initial pregnancy visit. And they do what they would do traditionally. They get a history and they get a physical assessment. And then they're invited to receive care in this way if they would like to.
Groups of eight to 12 women who are going to deliver in the same month are grouped together. And ideally the best time to begin a group is, I think, right before you would have to run from room to room to talk about maternal fetal alpha protein, the triple screen or the quad screen. So that's a very nice time. But sites, that's not an essential element; so sites do that in a way that best fits their practice.
The physical assessment is done in a group space by a provider, so usually you have one provider who is an obstetrical provider and another provider, there's a lot of freedom about who is the person who would be most appropriate. Sometimes that's a peer outreach worker. Sometimes that's a nurse. Sometimes it's a counselor, social worker. It could be anyone in your system who has the skill and the interest.
Women do their own self‑monitoring of their weight and blood pressure. In sites where urine dipstick is still being practiced, of course Caring For Our Future says there's really no information we get from that. Sites are doing away with it. But there's no reason why women can't do their own dipstick. So there's ten two‑hour sessions that are facilitated by the group leader, usually the health provider, but, again, it depends who has the talent to do it. And so when you think about this, women have 20 hours of face time, really quality face time with their provider. That is an enormous amount of time to get to know women and their concerns to build a bond and to have an impact on outcomes.
The sessions focus on the issues of pregnancy and parenting, so it really follows the outline of prenatal care but also child birth education. And it's really ‑‑ for women who aren't getting prenatal education, certainly that's the plan of it. Women may not need to have separate child birth education but they may like to. The tool that helps to spring the discussion, each session has self‑assessment sheets. And they invite women to think about the topics that are going to be discussed in the curriculum, and that kind of springs the discussion.
So four sessions every four weeks in the first half of pregnancy and six sessions every two weeks in the second half of pregnancy. Caring For Our Future says there's no real basis for seeing women weekly at the end of pregnancy. However, if you want to do that, it may be a way for the women to get to know some of the providers in the practice, or if they need, if more visits are medically indicated.
So what does the assessment piece look at? It's self‑assessment, physical assessment and psychosocial assessment. The self‑assessment we've gone through a little bit. Women come in, take their own blood pressure; they get their own weight. They get to play with the wheel, which is always very empowering. I want to play with that thing. They get to write in their own chart, then they start to think about the self‑assessment sheets.
And here's a picture you can see the woman in the front is weighing herself. The woman seated next to her is taking her blood pressure with a wrist cuff. We find those work very well. They're not expensive. They're like $69. There are also some self‑cuffs you can do on the arm. In the back, it's hard to see, you can see a head peeking up. There's a woman on the mat. There's a mat on the back of the room. There's some music provided. That creates kind of an auditory screen, and women will kind of stream into the room, they'll start their own process by getting their weights and their blood pressures, writing in their chart. There's the nurse or the person who is the second group facilitator will help them with that process, make sure they get through it right. The women who are seated around are working on their self‑assessment sheets, and one by one the women will go over to the mat and they'll have intense private time with the obstetrical provider; they'll do the chart review, fundal height and heart tones. The self‑assessment sheets really look like the content of prenatal care and the things we talked about in the beginning.
Thinking about breast feeding, contraceptive use, and domestic violence, all kinds of things, family process, that can be addressed in that capacity.
The physical assessment, that's the mat. That's the time where people get together on the mat. And it's the physical checkup. It's the same exam they would get in a one‑on‑one room in ten minutes.
So here's a little bit what this looks like. It's a very intense time. It's private, because you know below the sight line of women who are sitting in chairs, there's music that creates an auditory screen. It's a time to be very focused on what's going on with this woman and her partner. And this is what people say about it: "Well, it was no big deal. It gets easier. Everyone has the same marks. You know, once you have a baby you have no modesty anyway." So these are kind of people's comments.
People's comments about listening to heart beats: "You know, oh, his heart was good. It was really fun for me. You could hear other heart beats." It normalizes things very quickly. And people really bond around this. "I think it was as much of a reassurance for us as it was for each individual mother, so everybody is okay."
The psychosocial assessment, we want to make sure, and particularly in our populations, that people have sufficient support; that their basic necessities are met, that they are in a safety environment and that they're adjusting well. Some of those things are assessed on the mat in that intense private time. But some of those things if you sit for two hours with these women ten times in a row you really get a sense of are they adjusting all right and are they safe and are they well.
So this is what the mat time looks like. Again, it's very intense personal time. Education component. Really anything that you can think of that's part of prenatal education or prenatal care is comprised in the curriculum. And, again, these are not essential elements. You can add content as you need to for your site.
But these are things that you know you can discuss in a really meaningful way and not a cursory way, that is something that's really a luxury in traditional care. And you're in a group. You can throw a mat down and you can practice, you know, you can practice comfort measures for back labor. So there's really some flexibility. And it's a lot of fun. So here's some people, here's pelvic rocking for back labor.
Here's what people say about the educational component: "I learned more than I could ever tell. A lot more ‑‑ I read a lot of books. I learned more than I could learn from book by coming to group." "If someone wouldn't ask a question, someone else would." And I think that's really one of the great values of this model, is that there are people who, you know, you forget to ask something or you're shy. You don't want feel comfortable but someone else will. So things become normalized and things come out and there's really an opportunity to get a lot of education.
The support component: Again refreshments are very important. Women bond around food. You need to make time for formal and informal sharing. So that happens a lot during the picture where everyone was doing their assessment. You know, the women will take their blood pressure. They'll do their charting. They'll do their self‑assessment sheet, then they'll sit down and chat, what's going on with you. It's a time for them to bond and the stability of the group and the sort of gelling of the group happens around that.
Oftentimes women want to exchange names and telephone numbers and want reunions and these women stay together.
Consistency of leadership is very important in this regard, because it really helps to, you know, to make the group a consistent, safe place. So here's a reunion. Women and families really like to get together afterwards and see each other's products.
And here people say, this is some of the things people say about support. "You knew you were going to be with people who you knew were going through the same thing. They became another group of friends, or somebody shared a problem you had and you thought you were the only with you. You come to the group and say we had that problem, too. It's nice because you were with people who were really concerned about you."
I'll go quickly, because really I'm setting the stage for Jane and Chan; they'll talk about their site specific data. But I thought I would go quickly through, when Sharon was piloting this in her site, she did it in two places at the same time. One was at the public health clinic, prenatal clinic tied to a hospital, young population, ethnically diverse population. And then the other site was a private practice, pretty middle, upper middle class, mostly couples. And so she was looking at ‑‑ the goal she was looking at for piloting the program were really goals for the system. She was looking for a way to attract more patients, to provide care that was cost‑effective, and she wanted to see what the effect would be for outcomes. And she really was looking to promote staff growth, her own and also some of the nursing staff she felt was being really underutilized, was hoping to find ways to draw in some of the talent that she had that wasn't being used effectively; and for patients she really was hoping to find ways to get them to become more involved in their care and have safe outcomes.
So here's a list of some of her outcome objectives. Satisfaction, attendance, emergency room use, learning and support and safe birth outcomes. So how did it go? Basically what I wanted to point out for this is the attendance was excellent, particularly in the teens. 92% of the teens. There were teen groups where nobody missed a single session, which I think is, you know this is really good model for teens because they are so peer oriented. Emergency room visits.
Again, this has an informal comparison group, and it's a very small sample, but emergency room visits particularly in the third trimester really went down. And when I think it's because people, you know when people would call, they would say, well, okay, I've done this, I've done this, I've done this, I've done this and I'm still having this, and that's why I'm calling. It's a different quality of phone call than the phone calls or the kind of visits that you get, urgent care visits.
What people said about the education component: A high number said they felt they liked it very much and they were prepared for labor and delivery. In terms of support, again, people really felt they got to know each other, enjoyed being together and wanted to get together after delivery.
These numbers for preferring for overall evaluation are constant across the country and all kinds of sites. Really around 96% of women say they prefer to get their care in this way.
So here's some things that they said. "We came at the same time. We left at the same time. And something happened the whole time we were there," which is really not usually what happens, right? Would they do it again? "We're all planning when we have our next baby so we can have the same group. We have to send around a note, time to get pregnant again.
This is a profound and important comment. "Although it was a group, it seemed more intimate. More time was spent on specific issues that I'm not sure would have been brought up with a provider in a ten minute session. We are very happy we joined the group enjoyed and met all the people. I think we've seen it over and over again in groups. It's really amazing how the group provides a kind of safety and intimacy. And people will come out with things that you would never expect them to come out with. Issues of sexual abuse, drug abuse, family violence, PICA, eating clay and chalk, starch and where do you get yours, I get mine ‑‑ my grandmother says this was the best kind. Nothing you would be privy to. It's an honor to be led into the circle.
And this is from one of the group leaders I think out in Berkeley . "Centering has almost an instant effect on women who immediately understand the difference between this kind of care and other care, being treated in a way that feels more respectful to them. Everyone there speaks their language. This is really significant for people who are being bombarded by a culture that they feel just doesn't really see them. It thoroughly demystifies things." And this is a model of care that has great potential to be, to honor people from different cultures.
Quickly, this is the, just to sort of contrast the public health clinic and the private practice setting, because some people think, well, this could be a good model for teens or good model for this kind of people or that kind of people. What we found is people like this model, all kinds of people.
People felt comfortable with men in the group during assessment. They were satisfied with the care. They preferred this kind of group than being in an exam room. They were comfortable doing their own self‑care. They felt the environment was intimate for private questions. And there are a few things that you'll have to see people for afterwards, but you try really to limit that.
100 percent got to know other people, wanted to get together after delivery. And this is an interesting comment, you know, "It was fun listening to what people felt about pregnancy, to learn that I wasn't the only one family feuding about the baby."
So it has a great capacity to normalize a lot of the issues that people go through in pregnancy. This is one of the workshop groups came up with this, which is kind of cute, centering: Care in a circle, education, nutrition, trust, empowerment, relationships, involvement nurturing and growth. We kind of like that, because when you get to know everybody, you get to care about everybody. And I think that has great impact on quality of healthcare.
So I want to talk briefly before my time is up about the Yale University research. This is the match cohort study that was published in the Green Journal in November of '03. The data is from Yale Newhaven Hospital and Grady Memorial Hospital at Emery. It's a matched cohort study into two sites. The sample size is 458. And the patients were matched on age, race and parody and closest day of delivery.
I should mention that the primary investigator on this study is Janet Ikovitz. Some of you may know, she's really renowned HIV researcher.
So, again, more on the sample. And some things that people in the study have said: "I get all the attention I need and there's no waiting." That's a big deal for people.
"Great way to learn about your body." "Felt ready." "Being able to talk openly and getting feedback is very helpful." So patient satisfaction again very high. Across the board we've seen very high ratings for patient satisfaction. People like the organization of being in a group, learning about prenatal care, being with other women, feeling prepared to care for new baby and to go through labor and delivery.
This is where I said that Jennifer House set us up very nicely, because we are so concerned with very low birth weight babies and preterm babies. And basically I'm going to go to the take‑home, this is ‑‑ the take‑home message from this study is if you were to have a preterm baby, if you were in a centering group, you would keep your baby in two weeks longer and it would be on average a pound heavier. So when you think about those very low birth weight babies, those two weeks and that extra pound are extremely significant in how they translate into outcomes. And this is something that is a really big drain on our system and a really big concern to all of us.
And it was very significant. This was the precursor to the randomized control trial that's ongoing at Yale and Emery. Again, attendance was excellent. And here's a little bit about the randomized control. It's a longitudinal perspective study, randomly assigned participants to one of three conditions. There's standard traditional prenatal care and then what we call traditional or standard centering, and then there's some enhanced content around HIV risk behavior and knowledge. So some skill building activities for HIV and STD prevention.
This study sample are young pregnant women. They're HIV negative at enrollment. And they're low risk normal pregnancies.
English or Spanish speaking. There's 1120 participants. Their outcomes are going to be pregnancy outcomes, birth outcomes and behavioral outcomes.
(Inaudible) communication so sex‑related outcomes, knowledge and satisfaction and some psychological outcomes in terms of depression and self‑esteem and prenatal distress.
We're expecting the women in centering pregnancy to have better birth outcomes and better psychological outcomes than those who get standard individualized care. We expect the people in the enhanced group will have better biological behavior and sex related outcomes than those who get the centering and standard individualized care and this again, the content of the education in centering is not one of the essential elements. So it can be tailored or modified to your population.
Briefly, I think just before I turn it over, I wanted to just mention some things that we can talk about in questions and answers, but you probably know about the perinatal collaborative that's working on best practices for, to be pilotted in the community health centers? And Sharon Rising is part of that perinatal collaborative. There's a lot of excitement about the centering model in this collaborative. And the outcomes they're having to address are patient safety but also disparities in African American population. There's great excitement about centering. It's planned to be pilotted in five community health centers, in Chicago , Detroit , Mississippi and South Carolina . And there's also the military study that was alluded to earlier. So we can talk more about that in questions and answers if you would like. And thank you very much I'll turn it over to Chan.