Strong Start for Mothers and Newborns
The Centers for Medicare and Medicaid Services (CMS) awarded UAB one of 27 grants through the Strong Start for Mothers and Newborns program, which is aimed at addressing factors in pregnant women that increase their risk for preterm birth and other poor pregnancy outcomes. The program is made possible by the Affordable Care Act.
UAB will receive approximately $750,000 over four years to test the Maternity Care Home model, one of three maternity care service approaches that will be examined through the Strong Start initiative. “We will establish Maternity Care Homes for patients who are at risk for adverse perinatal outcomes,” says Joseph Biggio, MD, Director of the UAB Division of Maternal-Fetal Medicine and principal investigator for the UAB Strong Start program. “Through these maternity care homes, we will provide enhanced risk assessment services for patients. Once risk factors are identified, we can work to ensure patients have access to the care they need to either eliminate or reduce the risk to the pregnancy.”
The Strong Start effort is a four-year initiative to test enhanced prenatal care interventions for women enrolled in Medicaid or the Children’s Insurance Program (CHIP) who are at risk for having a preterm birth. The goal is to determine if these approaches to care can reduce the rate of preterm births, improve the health outcomes of pregnant women and newborns, and decrease the total cost of medical care during pregnancy, at delivery and over the first year of life for children born to mothers in Medicaid or CHIP.
Biggio says the UAB Strong Start program will focus on risk assessment in four predominant areas. One area of focus is nutrition and gestational weight gain. ”The program will target women who are either underweight or obese at the time of entry to care. Both problems put the patient at risk for preterm birth, pregnancy complications and childhood obesity,” he says. “We will encourage women to adopt a healthy diet and will stress the benefits of breastfeeding for the health of mothers and their babies.”
Additional areas of risk assessment include screening for substance abuse and smoking. “If we identify substance abuse, we will get the patient into a treatment program,” Biggio says. “Pregnancy represents a unique opportunity to try to change behaviors associated with poor health outcomes. We hope to use screening for these problems and leverage the identification of at-risk patients into an opportunity for patient education and motivation for behavioral change.”
A final area of risk assessment will include screening for depression. “Up to 25 percent of pregnant women have evidence of depression. Women who are depressed have an increased risk for low birth weight babies, preterm delivery, and worsening depression post-partum,” Biggio says. “Our program will identify women with significant depression, offer counseling, and ensure access to pharmacologic therapy when needed.”
Alabama Perinatal Excellence Collaborative
Biggio and his UAB colleagues also are working to improve outcomes for patients across Alabama through involvement in the Alabama Perinatal Excellence Collaborative (APEC). APEC is a partnership between the Departments of Obstetrics and Gynecology at UAB and the University of South Alabama, the Alabama Medicaid Agency Maternity Care Program, the Alabama Department of Public Health, and several community physicians. The aim of the collaborative is to develop evidence-based obstetric care guidelines and best practices, quality benchmarks and resources to link community providers and patients to tertiary center expertise.
“We know that there is wide variation in how obstetric care is delivered in this state,” says Robert Moon, MD, Chief Medical Officer and Deputy Commissioner of Health Systems for the Alabama Medicaid Agency. “The goal of this collaborative is to bridge the gap between scientific understanding and patient care, and to guide OB providers toward meeting new benchmarks of quality care so mothers can have safe pregnancies, and babies can get a healthy start to life.”
This venture began 16 months ago with the task of developing a mechanism for providing evidence-based, standardized practices for obstetric care in Alabama.
“You can look at any industry in the country and see that standardization of management improves results. In medicine, that same principle applies,” Biggio says. “Our goals are to have protocols developed to guide obstetric care that are based on the best data. We want physicians and patients in Alabama to have access to the best recommendations regardless of whether they are being seen at one of our academic tertiary care centers or at an outlying hospital hours away.”
In addition, each protocol has quality benchmarks to allow assessment of performance and provision of feedback. “Pay for performance will become an increasingly important part of reimbursement,” Biggio says. “We want to get in on the ground floor and assess how we are performing based on key obstetric benchmarks before CMS and other payers implement their own measures.”
In writing the guidelines, Biggio says they began with a basic primer of baseline expectations for prenatal care, which includes labs and assessments. “From there, we targeted common problems that physicians deal with and for which they seek assistance,” he says. “With the assistance of Allison Todd, the administrative director of the program, we have developed guidelines specific to gestational diabetes, prior preterm birth, preeclampsia, pre-gestational diabetes, and chronic hypertension. We will continue to evolve and develop guidelines for the foreseeable future expanding to encompass as many areas in obstetrics as possible.”
Moon says that this measurement of providers’ progress toward meeting the APEC benchmarks is one of the most important aspects of this effort. “Assessing those benchmarks requires the collection of data that provide an accurate measurement of how well those benchmarks are being met. And if they are not being met, we want to know why,” he says.
Alabama Medicaid, along with the federal government and insurers, will look at outcome measurement and how that can be used to create incentives to drive quality and value-based purchasing for care. “For example, one measure is how many elective deliveries before 39 weeks of pregnancy were not medically indicated,” Moon says. “There is evidence that pre-term deliveries without a medical reason often jeopardize the infant’s health and result in preventable admissions to neonatal intensive care units. That is something we can measure, and this data can provide the basis to help a doctor or hospital address barriers to change.”
The Alabama Medicaid website has a section for APEC where all guidelines are posted for review in draft form, so obstetric providers can review them and provide feedback before the protocols are finalized. The Alabama Department of Public Health is further assisting the collaborative by developing marketing plans to help make providers around the state aware of the resource.
Both these initiatives have an opportunity to impact the cost of care for pregnant women and their babies. “One of the major drivers of health care expenditures is the cost of caring for preterm infants,” Biggio says. “500,000 infants are born preterm each year and incur a total cost of about $26 billion. And that’s just the short-term costs. Many of these children continue to have lifelong issues that accrue costs as well. If we can reduce the rate of premature births by even one percent, we can dramatically reduce the cost of care and improve the health of future citizens of Alabama.”
Biggio hopes that APEC will help provide patients throughout Alabama access to expertise that otherwise might not have been available if they were not treated at one of the tertiary centers in the state. “Through use of these evidence-based protocols, we hope obstetricians will be able to provide the best care possible the greatest number of times and avoid the provision of unnecessary care the greatest number of times,” he says. “If we do that, we will have the direct benefit of cost savings and improving outcomes of both mother and child.”
Moon agrees and adds that the ultimate success is to see measurable improvement in Alabama’s infant mortality rate and also a reduction in the number of babies born too soon or with disabling conditions. “This effort has enormous implications for the health and well-being of the children in our state,” he says.