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MCHB Programs In Support of the Preemie Act

Hani K. Atrash MD, MPH

Director

Division of Healthy Start and Perinatal Services (DHSPS) Department of Health and Human Services (HHS)

Health Resources and Services Administration (HRSA)Maternal and Child Health Bureau (MCHB)

Meeting of the Secretary’s Advisory Committee on Infant Mortality, August

10-11, 2015Washington, DC

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The PREEMIE Reauthorization Act

Reauthorizes… the Secretary of HHS to conduct demonstration projects related to preterm births …. to test and evaluate various strategies .. on:

(1) the core risk factors for preterm labor and delivery,(2) medically indicated deliveries before full term,(3) the importance of preconception and prenatal care,(4) treatments and outcomes for premature infants,(5) meeting the informational needs of families during the stay of an infant in a neonatal intensive care unit, and(6) utilization of evidence-based strategies to prevent birth injuries.

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HRSA Approaches to Improving Pregnancy Outcomes

• Preconception / Interconception health

• Life-course approach

• Collaborative Innovation Networks (COINS)

• Collective impact

• Backbone organizations

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National:• Secretary’s Advisory Committee on Infant Mortality

(SACIM)• National Maternal Health Initiative• Guidelines for Well Woman Care• Title V Transformation / Collaborative Improvement

and Innovation Network (COIN)

State/Regional:• Maternal, Infant and Early Childhood Home Visiting• Title V Transformation / Collaborative Improvement

and Innovation Network (COIN)

Local/Community:• National Healthy Start Program• Maternal, Infant and Early Childhood Home Visiting

Improving Pregnancy Outcomes – Levels of Support

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1. Improve the health of women2. Ensure access to a continuum of safe and high quality,

patient-centered care3. Redeploy key evidence-based, highly effective preventive

interventions to a new generation4. Increase health equity and reduce disparities by targeting

social determinants of health through investments in high-risk communities and initiatives to address poverty.

5. Invest in adequate data, monitoring, and surveillance systems to measure access, quality, and outcomes.

6. Maximize the potential of interagency, public-private, and multi-disciplinary collaboration.

MCHB supports SACIM’s National Strategy to Reduce Infant Mortality: the 6 Big Ideas

(1/2013)

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Title V Block Grant Transformation

1. Reduce burden • Reducing data reporting by prepopulating from federal

sources• Simplifying/clarifying and reducing the number of forms;

streamlining narrative and application

2. Maintain flexibility• Choice in national performance measures (8 of 15)• State-specific performance measures (3 to 5)• State-developed evidence-based/informed strategy

measures

3. Improve accountability and document impact • Fewer performance measures directly tied to Title V activities • New framework that tracks performance in relation to activities

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Performance Measure Domains

•Women’s / Maternal Health

• Perinatal/Infant Health

• Child Health

• Adolescent Health

• CSHCN

• Cross-cutting / Life Course

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Title V Performance Measures Related to Prematurity

1. Well Woman Visit: Past-year preventive visit among women ages 18-44 (%) (PM 1)

2. Low-risk Cesarean: Cesarean among nulliparous, term, singleton, vertex live births (%) (PM 2)

3. Adolescent Well Visit: Past-year preventive visit among adolescents ages 12-17 (%) (PM 4)

4. Smoking during pregnancy (%) (PM 14 A)

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Title V Outcome Measures Related to Prematurity

1. First trimester prenatal care entry

2. Severe maternal morbidity

3. Infant outcomes: Preterm birth  (<37 weeks gestation); Early preterm birth (<34 weeks gestation); Late preterm birth (34-36 weeks gestation); and, Early term birth (37,38 weeks gestation)

4. Early elective deliveries (37, 38 weeks gestation)

5. Mortality (infant): Perinatal mortality rate; Infant mortality rate; Neonatal mortality rate; and, Preterm-related mortality rate

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Women’s Health Preventive Services

Guidelines for Well Women Care

• Support the development of clinical preventive health guidelines for well woman visit

• Compile the guidelines into a succinct resource

• Disseminate these guidelines and promote their adoption into standard clinical practice among women’s health care providers

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National Maternal Health Initiative

• Goal: Promote coordination and collaboration within HRSA, across HHS agencies and with professional and private organizations.

• Priorities: Improving women’s health before, during, and after

pregnancy Improving systems of maternity care including

clinical and public health systems Improving public awareness and education Improving research and surveillance Improving the quality and safety of maternity care

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National Maternal Health InitiativeAlliance for Innovation on Maternal

Health (AIM)

• A four year $4 million cooperative agreement with the “Council on Patient Safety in Women’s Health Care” supported by the American Congress of Obstetricians and Gynecologists (ACOG)

• Goal: to prevent 100,000 severe complications during delivery hospitalizations and 1,000 maternal deaths by 2018

 • Approach: the development and rollout of

evidence-based patient-safety bundles

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National Maternal Health InitiativeAlliance for Innovation on Maternal

Health (AIM)

• Supports harmonized data-driven continuous quality improvement processes

• Provides evidence-based implementation resources to streamline bundle implementation

• Leadership team, in addition to ACOG, includes more than 25 organizations and agencies

• Continuous quality improvement efforts are data driven

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National Maternal Health InitiativeAlliance for Innovation on Maternal

Health (AIM)

• Safety bundles include: Obstetrical Hemorrhage Severe Hypertension/Preeclampsia Prevention of Venous Thromboembolism Support for Intended Vaginal Birth Reduction of Peripartum Racial Disparities Standards of Care for the Interconception/Postpartum Visit

• AIM facilitates multidisciplinary and interagency collaboration between states and hospitals

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The Infant Mortality CoIINThe Collaborative Improvement & Innovation Network to Reduce

Infant Mortality

• Designed to help States innovate and improve their approaches to improving birth outcomes

• Initiated March 2012 as a mechanism to support the adoption of collaborative learning and quality improvement principles and practices to reduce infant mortality and improve birth outcomes

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Regions IV and VI CoIIN: Strategies & Structure

5 Strategy Teams

1. Reducing elective deliveries <39 weeks (ED);

2. Expanding interconception care in Medicaid (IC);

3. Reducing SIDS/SUID (SS);

4. Increasing smoking cessation among pregnant women (SC);

5. Enhancing perinatal regionalization (RS).

Teams

• 2-3 Leads (Content Experts);

• Method Experts

• Data Experts

• Shared Workspace

• Data Dashboard

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Non-Medically Indicated Early Term Deliveries Among Singleton, Term

Deliveries*

* Based provisional birth certificate data; denominator excludes women with medical indications present prior to and during pregnancy

30% total decline translating to ~85,000 early elective deliveries averted since 2011 Q1

5 states met aim of 33% reduction11 states had declines of 20%+

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Smoking During Pregnancy*

* Based on provisional birth certificate data reflecting smoking in any trimester

12% total decline translating to ~18,000 fewer women smoking in pregnancy since 2011 Q1

6 states met aim of 3% reduction

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National CoIIN• 58 States & Jurisdictions• 6 Strategy Teams

• Safe sleep• Smoking Cessation• Social Determinants

• Preconception/Interconception Care• Prevention of Preterm and Early-Term Births• Perinatal Regionalization

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Preconception/Interconception Health n=29

LEGEND

Learning

Network

Chosen

=

Puerto Rico

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LEGEND

Learning

Network

Chosen

=

Prevention of Preterm & Early Term Births n=21(Progestogens & EED)

Puerto Rico

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LEGEND

Learning

Network

Chosen

=

Perinatal Regionalization n=14

Puerto Rico

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LEGEND

Learning

Network

Chosen

=

Smoking Cessation n=21

Puerto Rico

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LEGEND

Learning

Network

Chosen

=

Social Determinants of Health n=23

Puerto Rico

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• Established in 1991 as a presidential initiative

• Provides funding and supports communities with high infant mortality rates and other adverse perinatal outcomes

• Focused on community innovation and creativity and encouraged communities to do what was best for them

• Today, HRSA supports 100 healthy start projects in 37 States and Washington, DC

THE NATIONAL HEALTHY START PROGRAMHistory

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• Improve Women’s Health

• Promote Quality Services

• Strengthen Family Resilience

• Achieve Collective Impact

• Increase Accountability through

Quality Improvement,

Performance Monitoring, and

Evaluation

Main Changes to Healthy StartHealthy Start Approaches

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The Federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)

Provide voluntary, evidence-based home visiting services to pregnant women and families with young children

Budget grew from $100 million in 2010 to $400 million in 2014

In 2014, MIECHV supported 685 unique Local Implementing Agencies (LIAs) serving 115,500 parents and children in 787 counties in 50 states, DC and 5 territories

The program reaches those at the highest need (79% below poverty level, 34% of adults had less than high school education, and 67% were racial and ethnic minorities)

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The Federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)

• 8 of the 17 evidence-based models target pregnant women:• Early Head Start• Early Intervention Program for Adolescent Mothers• Healthy Families America• Maternal Early Childhood Sustained Home Visiting Program• Minding the Baby• Nurse Family Partnership• Oklahoma’s Community-Based Family Resource and Support Program• Parents as Teachers

• In 2014, 27% of newly enrolled households included pregnant teenagers

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For More InformationHani Atrash, MD, MPH

Director, DHSPS

5600 Fishers Lane, Room 13-91Rockville, MD 20857

Office: 301-443-0543Direct: 301-443-7678

Email: hatrash@hrsa.gov