Centering Pregnancy
Tailoring Models of Care for Populations
at Risk
Today’s presentation is supported, in part, by the March of Dimes, NIH Grant (5K23NR010747-02), & AEMC
Joan Rosen Bloch, PhD, CRNP
WHNP- HC # 10
Nursing & Public Health, Drexel University
Philadelphia, PA
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Objectives this afternoon
• Identify advantages of Centering Pregnancy for select
groups of pregnant women living in socioeconomically
disadvantaged neighborhoods.
• Describe the basics of Centering Pregnancy.
• Discuss strategies for implementation and model fidelity.
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Introducing a new model of care…
Why Centering Pregnancy for AEMC?
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Philadelphia Pregnant Women get
the BEST medical care
But, more than excellent medical care is needed, especially when living in
unhealthy communities
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Philadelphia is a City of Neighborhoods
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Where you live – matters
▫ Socio-economically disadvantaged neighborhoods
have worse perinatal health outcomes
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Where you live matters
Stressed Environments
Adverse Health Outcomes
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Neighborhood Exposure to Environmental Stress
Bloch, J (2011). JOGNN, 40. 544-554.
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housing
problems
ss
e
str
al
i
c t
so por
p
su
Biological Mediators
To Chronic Psychosocial
Stressful Exposures
Stres
s
Systemic Inflammatory State
neuroendocrine
changes
immunemodulation
Social support has the possibility to mediate/mitigate stress
Facilitating social capital may have long lasting benefits for
young families living in stressed neighborhoods
Centering Pregnancy
This is what we found out during our AEMC supported training,
July 14-15, 2011
CENTERING: a model for group health
care
CenteringPregnancy®
CenteringParenting
™
www.centeringpregnancy.org
You are a pregnant mom...
Imagine…
•
•
•
•
No waiting
A community of friends
Relaxed time with your provider
Opportunity to talk about pregnancy,
birth, parenting..even set personal goals
• Time for lots of discussion
• Fun at your visits
You are a provider...
Imagine…
• Having time to really listen to your moms
• Getting help from the group with
problem-solving
• Needing to say things only once
• Working with really activated patients
• Finding work fun and energizing
You are an administrator...
Imagine…
• Better access for your patients
• Freed-up exam rooms for paying
procedures
• Happy providers/staff….less turnover
▫ Provider must be present (CNM, NP, PA or
MD/DO)
• Great marketing program
• Better birth outcomes
• Predictable clinic time schedules
You are a learner...
Imagine…
• One-on-one precepting time focused on OB for 4
hours per month
▫ Great learning for nursing, public health and
medical students and residents
• Learning from peers and pregnant women
• Learning in a relaxed environment
Why Groups?
Time to share joys
and concerns
Build community
Creative problemsolving
Efficient way to
share information
Better evidencebased outcomes
Picture retrieved 1/2/12 from internet accessed PowerPoint by Barr, WB et al.,
Beth Israel Residency in Urban Family Medicine
Groups provide…
• A vehicle for social
change
• An opportunity to
learn from each
other
• Fun and
interesting
sharing
Picture retrieved 1/2/12 from internet accessed PowerPoint by Barr, WB et al.,
Beth Israel Residency in Urban Family Medicine
Growing body of evidence…
RCT results: Centering Pregnancy
Obstetric Outcomes*
•
•
•
•
Reduce prematurity (OR 0.67 [0.44-0.98], p=0.045)
Improved patient knowledge (p<0.001)
Enhanced patient satisfaction (p<0.001)
Higher breastfeeding initiation rates (OR 1.73 [1.28,
2.35], p=0.001)
Group prenatal care resulted in equal or improved perinatal outcomes
at no added cost
*Ickovics JR, et.al. Group prenatal care and perinatal outcomes: a randomized control trial. Obstet Gynecol.
2007;110:330-9.
Retrospective design: Picklesimer et al., May, 2012 AJOG reported 46% reduction in PTB (OR, 0.54; 95% CI, 0.31-0.93)
General Program Design
• Traditional First PNC visit before entry
into a group (individual visit)
▫ If appropriate for group care, invited to
participate
• Groups of 8 - 12 women, with same
month/block EDD invited to group
▫ Begin between 14-18 weeks GA
▫ Confidentiality agreement signed
▫ Partners encouraged to attend
Design: Schedule
Four sessions every 4
weeks
16, 20, 24, 28 weeks
Six sessions every
2 weeks
30, 32, 34, 36,
38, 40 weeks
Plan for a reunion
Between 1-2 months
postpartum
Additional visits as needed to address issues
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Design: Two-Hour Session
• 30-40 minutes
▫ Check-in self-assessments and individual
assessments with the provider
• 60-75 minutes: Education and Support
▫ Formal “circle-up” or facilitated discussion time
• Informal time for socializing: Support
▫ Closing and follow-up as needed
Self Assessment
• Women do selfmonitoring of:
▫ Current gest. age
▫ weight
▫ B/P
Picture retrieved 1/2/12 from internet accessed PowerPoint by Barr, WB et al.,
Beth Israel Residency in Urban Family Medicine
• Women document
data in the chart
(ACOG forms)
SELF-ASSESSMENT SHEETS for
CenteringPregnancy® (SELECTED)...
• Nutrition
• Common Pregnancy
Problems
• Family Issues
• Parenting Styles
• Relaxation Measures
• Comfort Measures for
Labor
Individual Physical
Assessment
• Individual
physical
assessment done
within group
space
by a provider
Picture retrieved 1/2/12 from internet accessed PowerPoint by Barr, WB et al.,
Beth Israel Residency in Urban Family Medicine
Education
• 10 two-hour sessions
facilitated by group
leader, health care
provider present
(billable service)
• Visits in circle
• Facilitated leadership
• Outside speakers
Picture retrieved 1/2/12 from internet accessed PowerPoint by Barr, WB et al.,
Beth Israel Residency in Urban Family Medicine
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Education
Content
Support and Community
Building
• Refreshments
• Formal and
informal sharing
• Stability of group
• Exchange of
names, telephone
numbers
• Consistency of
leadership
Picture retrieved 1/2/12 from internet accessed PowerPoint by Barr, WB et al.,
Beth Israel Residency in Urban Family Medicine
Closing the Visit
• Future date reminders
• Individual chart reviews - patient,
resident, attending
• Social time
• Charting (EHR)
▫ After patients leave
▫ Team reviews cases and determines if any outreach or
follow-up is needed
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Fidelity of the Model
13 Essential Elements
1. Health Assessment occurs in group space
2. Participants involved in self-care
3. Facilitative leadership style
4. Each session has an overall plan
5. Attention given to content: Emphasis
may vary
6. Stability of group leadership
7. Group conduct honors the contribution of
each member
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Fidelity of the Model
13 Essential Elements (cont.)
8. The group is conducted in a circle
9. Opportunity for socializing is provided
10. Composition of group is stable, not rigid
11. Group size is optimal to promote the
process
12. Involvement of family support is optimal
13. There is ongoing evaluation of outcomes
Administrative Challenges
Reported from Beth Israel Urban Family Medicine Residency Program
WB Barr et al., Using centering
pregnancy to teach prenatal care:
Implementing group PNC in a
family medicine residency
(retrieved 1-2-12 from
internet www.fmdrl.org/index.cfm?event=c.getAttachment&riid=3557)
Scheduling
• Evening clinic best to recruit patients into group
(also most cost effective as it’s a shorter session)
• R1 resident work hour concerns (do not usually
do an evening clinic)
• Coordination of schedules for attending,
residents, and clinic
• Need good prenatal coordinator!
Resident Continuity With Group
• Block Scheduling for
resident deliveries
• 2 person resident
prenatal teams
• How to deal with
existing patients
▫ Temporary transfer to
prenatal team
▫ Share care between
PCP and prenatal team
Resident Advantages to Group
“I had a great education experience...I was able to
learn from my patients, other residents, and
attendings. I was able to use my new found
knowledge in my regular clinic session with
those patient not in group. In addition, I bonded
with patients and got to know them better than I
would have in a regular session. If I were to
practice OB care in the future, I would definitely
do group visits.” R3 Family Medicine Resident
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Can we do Centering Pregnancy?
…besides innovative exemplar places like 11th St Corridor?
• Yes! Even though Philly is a conservative
medical town ☺
• More information:
▫ Centering Pregnancy Website
www.centeringhealthcare.org/
• Watch a session in action:
x You tube “Centering Pregnancy”
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In Conclusion…
Centering Pregnancy is one strategy
Bringing ‘upstream’ factors ‘downstream’
to mothers and their families at the point of care
We must think ahead and work in all ways possible to create healthier communities
for our babies born today
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The definition of insanity is doing the
same thing over and over and
expecting different results
…Ben Franklin..or Albert Einstein