kaiser permanente’s early start program conference... · the screening questionnaire is a...
TRANSCRIPT
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Kaiser Permanente’Early Start Perinatal Substance
Abuse Program
Kaiser Permanente’s Early Start ProgramA Successful Perinatal Substance Abuse Intervention
ANDREA GREEN, PSY.D AMY CONWAY, MPH EARLY START SPECIALIST EARLY START DIRECTOR
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Topics
▪ Overview of Northern California Kaiser Permanente
▪ Early Start Mission and Description
▪ Improved Health Outcomes and Cost Savings
▪ Operational Implementation
▪ Keys to Success
▪ Addressing Common Barriers
▪ Discussion
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Kaiser Permanente Northern California
▪ 4.2 million members
▪ 47,000 births in 2017
▪ 14 hospitals with labor and delivery units
▪ 57 outpatient prenatal clinics
▪ Covers ~50,000 drivable sq. miles
▪ 40 Early Start Specialists
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What is Early Start?
An award winning perinatal substance abuse program integrated into the OB clinic as part of prenatal care
Early Start improves outcomes for mothers and babies and provides a net cost benefit
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Early Start Mission
We believe that every woman deserves a non-punitive health care environment where she has access to services and support to have an alcohol, tobacco and drug free pregnancy, allowing the delivery of a healthy baby.
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Key Components of Early Start
▪Universal screening by urine toxicology screening and questionnaire
▪ Substance abuse specialist stationed in the prenatal clinic
▪ Counseling visits linked with routine prenatal care visits
▪ Assessment, education, and early intervention with patients
▪Ongoing counseling and case management
▪ Provider education and consultation
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Universal Screening
▪ Urine toxicology is included in the panel of standard prenatal lab tests
▪ The screening questionnaire is a combination of TWEAK and CAGE questions
▪ It asks frequency of use of nicotine, alcohol and other drugs in the 12 months before pregnancy and since pregnancy
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7Source: SAMHSA 2013 National Survey on Drug Use and Health; p 51 https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
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Source: SAMHSA 2013 National Survey on Drug Use and Health
https://www.samhsa.gov/data/sites/default/files/spot123-pregnancy-alcohol-2013/spot123-pregnancy-alcohol-2013.pdfs
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Marijuana Use in Pregnancy Increasing
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Source:Trends in Self-reported and Biochemically Tested Marijuana Use Among Pregnant Females in
California From 2009-2016; Journal of the American Medical Association 2017; 318(24) : 2490–2491.
doi:10.1001/jama.2017.17225
https://jamanetwork.com/journals/jama/fullarticle/2667052
Age 2009 2016
< 18 years old 12.5% 21.8%
18-24 9.8% 19%
25-34 3.4% 5.1%
>34 years old 2.1% 3.3%
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Will insert opioid prevalence here
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Early Start Drugs of Choice Over Time Based on Positive Toxicology Screen
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The Need for Perinatal Substance Abuse Programs like Early Start
Substance abuse during pregnancy is recognized as a serious problem with significant adverse neonatal outcomes such as:
▪ Placental abruption
▪ Fetal death
▪ Premature delivery and subsequent complications
▪ Babies who are small for gestational age
▪ Fetal Alcohol Spectrum Disorders
▪ Newborn Opiate Withdrawal
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▪ To decrease substance use in pregnant women
▪ To reduce negative birth outcomes and medical costs associated with prenatal substance abuse
▪ To improve access to substance abuse services for pregnant women
▪ To enhance provider satisfaction and efficacy
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Four Objectives of Early Start
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▪ NET COST BENEFIT: Decrease in neonatal hospital costs > cost of providing the prenatal intervention
▪ Improves maternal and infant outcomes
▪ Reduces the utilization of medical and social resources
▪ Enhances provider satisfaction and efficacy
Benefits of Early Start
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Early Start Workflow
Screening Questionnaire &
Urine Tox
Individualized Care
Plan
Prenatal Patient
Population
Early Start Assessment
Positive Assessment
At-Risk Not At-Risk
No further action
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A Story…
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Early Start Research
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Published Research on Early Start
▪ Trends in Self-reported and Biochemically Tested Marijuana Use Among Pregnant Females in California From 2009-2016
Kelly C. Young-Wolff, PhD, MPH; Lue-Yen Tucker, BA; Stacey Alexeeff, PhD; Mary Anne Armstrong, MA; Amy Conway, MPH; Constance Weisner, DrPH3; Nancy Goler, MD4; Journal of the American Medical Association 2017; 318(24) : 2490–2491. doi:10.1001/jama.2017.17225
▪ Early Start: A Cost-Beneficial Perinatal Substance Abuse Program
N Goler MD, MA Armstrong MD, V Osejo BS, YY Hung PhD, M Haimowitz LCSW, A Caughey MD; Journal of Obstetrics and Gynecology Volume 119, No 1, Jan 2012; pp 102-110
▪ Substance Abuse Treatment Linked with Prenatal Visits Improve Perinatal Outcomes: A New Standard
N Goler MD, MA Armstrong MD, C Taillac LCSW, V Osejo BS Journal of Perinatology April 2008
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Substance Abuse Treatment Linked with Prenatal Visits Improve Perinatal Outcomes: A New Standard
Study Methods
▪49,261 female KP members with birth at KP NorCal Hospital
▪Completed Prenatal Substance Abuse Screening Questionnaires 01/99 - 6/03
▪Urine toxicology screening test
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Methods
Definition of Study Groups
▪ SAF: Screened pos, Assessed pos, Follow-up (2,032)
▪ SA: Screened pos, Assessed pos, no follow-up (1,181)
▪ S: Screened pos (with tox), no assessment, no follow-up (149)
▪ C: Screened negative (45,899)
Maternal outcomes - prenatal through one year post-partum
▪Inpatient and outpatient costs
Infant outcomes - birth costs (hospital) through one year of life
▪Inpatient and outpatient costs
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Data Patterns
▪No statistical difference in any outcomes between the Early Start group (SAF group) who got assessment and follow-up and Control group
▪The group that screened positive and had no assessment or follow up (S group) had statistically worse outcomes and higher costs than the SAF and C groups
▪The women who only had the initial assessment (SA group) had intermediary results
Key:
SAF (2,032): Screened pos, assessed pos, follow-up
SA (1,181): Screened pos, assessed pos, but no follow-up
S (149): Screened pos (including toxicology),no follow-up
C (45,899): Screened negative
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With a coordinated program like Early Start,at risk patients’ birth outcomes match controls
e.g. Preterm Delivery (<37 weeks)
8.1%
9.7%
17.4%
6.8%
0.0%
5.0%
10.0%
15.0%
20.0%
SAF SA S Controls
Note: The rate of Preterm Delivery is 2.1 times higher in S group
than SAF (Early Start patients)
Key:
SAF: Screened pos, assessed pos, follow-up
SA: Screened pos, assessed pos, but no follow-up
S: Screened pos(including toxicology),no follow-up
C: Screened negative
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Rate of Neonatal Assisted Ventilation
3.2%
4.2%
6.9%
2.2%
0.0%
2.0%
4.0%
6.0%
8.0%
SAF SA S Controls
The rate of the babies needing a ventilator is 2.2 times higher in the S group that the SAF and
3.1 times higher than the controls.
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Key:
SAF: Screened pos, assessed pos, follow-up
SA: Screened pos, assessed pos, but no follow-up
S: Screened pos(including toxicology),no follow-up
C: Screened negative
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Rate of Placental Abruption
0.9% 1.1%
6.5%
0.9%
0.0%
2.0%
4.0%
6.0%
8.0%
SAF SA S Controls
Placental abruption is 7 times more likely in the S group
Key:
SAF: Screened pos, assessed pos, follow-up
SA: Screened pos, assessed pos, but no follow-up
S: Screened pos(including toxicology),no follow-up
C: Screened negative
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Rate of Intrauterine Fetal Demise (IUFD aka stillborn)
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
SAF SA S Controls
0.5% 0.8%
7.1%
0.6%
Stillborns (IUFDs) were 14.2 times more likely in the S group than the SAF or C groups
Key:
SAF: Screened pos, assessed pos, follow-up
SA: Screened pos, assessed pos, but no follow-up
S: Screened pos(including toxicology),no follow-up
C: Screened negative
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Maternal and Infant Mean Costs Comparison
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
SAF SA S Controls
Maternal Total Costs Infant Total Costs Maternal and Infant Costs Combined
Key:
SAF: Screened pos, assessed pos, follow-up
SA: Screened pos, assessed pos, but no follow-up
S: Screened pos(including toxicology),no follow-up
C: Screened negative
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Cost-Benefit Analysis
▪ Compared the total cost differences between SAF and SA groups to the S group including the costs of the ES program
▪ The total ES Specialist salary costs for providing care to the study cohort over 3.5 years totaled $2,347,100 or $670,600 annually
▪ By providing ES to this study cohort we provided an overall cost savings of $23,160,694
▪ Assumes outcomes of the S group for the SAF and SA group
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When there is a coordinated program like Early Start, net cost savings are realized
▪Kaiser Permanente Northern California realized a net cost benefit of $20,813,594 over 3.5 years for a cohort of 49,261 pregnancies or $5,946,741 annualized.
▪Early Start shifts cost spending from the costs associated with preterm births and other negative birth outcomes to their prevention.
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Within 12 months of implementation, Early Start, will not only improve outcomes for
mothers and babies, it will provide a net cost benefit for your organization.
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What could have been for the “S” group (149)?
➢If only they had also gotten to Early Start:
◦ 15 more term babies◦ 6 more babies breathing without a ventilator◦ 9 more women not experiencing an
abruption
◦ 10 more babies alive
The “S” Group
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What leads to success?
Medical Imperative: Doing the
Right Thing
Physician Leadership
Data Driven
Human Factors and Systems
Support
Cost Effectiveness
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Keys to Success – Staff and Provider Education & Engagement
▪ Educate ObGyn staff and providers on positive health outcomes with regular reminders and presentations
▪ Tell patient stories to dispel assumptions about who uses substances
▪ Engage frontline staff to help encourage patients
▪ Have a physician champion who can work with doctors who may need help
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Keys to Success – Reporting
Create reports to monitor performance◦Tracking reports
◦Missed Opportunity reports
◦Diagnoses rates etc.
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Common Barriers to Address
Resources
◦Hospitals are not motivated to
save costs by moving funds to
the outpatient setting
◦Willingness to risk new budget
for greater savings
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Common Barriers to Address
Denial among healthcare providers
◦Denial of substance use disorder as a
disease
◦Denial that intervention will work
◦Denial that women want help
▪ Considered a difficult patient population
▪ Mandated reporting laws
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Questions and Discussion
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Appendix
APPENDICES
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Mean Cost for Preterm Birth: 33-36 weeks (per baby)
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
SAF SA S Controls
Note: The birth rate at this gestation age is 1.6 times higher in the S than SAF group at this
Gestational age. No significant cost differences between the SAF and C groups, suggesting
ES reduces costs in this high-risk population to the overall baseline.
Key:
SAF: Screened pos, assessed pos, follow-up
SA: Screened pos, assessed pos, but no follow-up
S: Screened pos(including toxicology),no follow-up
C: Screened negative
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Mean Cost for Maternal Emergency Services
$0
$100
$200
$300
$400
$500
$600
$700
SAF SA S ControlsNote: ED costs for the S group are 1.8 times higher than the SAF group and 2.5 higher
than the C group.
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Mean Cost for Maternal Mental Health
$0
$20
$40
$60
$80
$100
$120
$140
$160
SAF SA S ControlsNote: An increased use of mental health services allows a mother to express her experience
and serves to normalize feelings of frustration and helplessness which could result in an
increased risk of post-partum depression.
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Early Start Timeline
1990
Pilot
Study
1993
Early
Expansion
4 Sites
1994-2000
PSANO
Study
published
+16 Sites
Database
started
2000-2004
Awards,
Business
Case, Entire
Region
Funded
2006
ES in all
NCAL
clinics
2008
PSANO II
the
PSANO II
economics
published
1990 1993 1994-2000 2000-2004 2006 2008-2012
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Binge Alcohol Use by Pregnancy Trimester
NP*, No Child 32.6%
Trimester 1 8.0%
Trimester 2 1.8%
Trimester 3 1.0%
NP, Child <3 months 10.0%
NP, Child 3-5 months 15.5%
NP, Child 6-8 months 14.6%
NP, Child 9-11 months 16.9%
NP, Child 12-14 months 17.6%
NP, Child 15-17 months 16.8%
NP, Child 18+ months 19.7%
* NP = Non-Pregnant
Cermak, Timmen L., M.D., Past president of the California Society of Addiction Medicine (CSAM).
(September 2012), Addiction as a Brain Disease, Presentation at the Early Start Regional Team
Meeting, Oakland, CA
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Amy Conway– Early Start Regional Director [email protected]
Deborah Ansley, MD – Early Start Medical Director [email protected]
Sharon Q. Wi – Early Start Lead Consultant
Karis Coleman – Early Start Project Manager [email protected]
Early Start Team Contact Information