INNOVATION NETWORK (COIIN) TO REDUCE INFANT MORTALITY IN MISSOURI - - PowerPoint PPT Presentation

COLLABORATIVE IMPROVEMENT & INNOVATION NETWORK (COIIN) TO REDUCE INFANT MORTALITY IN MISSOURI

Venkata PS Garikapaty, MSc, MS, PhD, MPH

Lead Maternal and Child Health Epidemiologist Missouri Department of Health and Senior Services Email: Venkata.Garikapaty@health.mo.gov

10/08/2015

FLOURISH Cabinet Meeting, St. Louis City, MO

OBJECTIVES

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 Infant Mortality in US and

Missouri

 CoIIN Project to Reduce

Infant Mortality

 Missouri CoIIN Priorities  Title V MCH Block Grant

and CoIIN Priorities

Definition

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 Infant Mortality - death of a baby before his or

her first birthday

 Infant Mortality Rate (IMR) is an estimate of the

number of infant deaths for every 1,000 live births

 Indicator of a nation’s health and well-being

INFANT MORTALITY RATE (IMR): Number of resident infant deaths x 1,000 Number of resident live births

IMR’s: Selected Organization for Economic Co-operation and Development Countries, 2010

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Source: http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf

Percent change in IMR by state: US, 2005-2013

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Source: http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf

MCH Profile – Missouri

 Missouri Population – 6 million (85% white, 12% AA)  Women population – 51% (84% white, 13% AA)  0-19 year old population – 25% (81% white, 16% AA)  34% of women in childbearing age (18-44 years) (82%

white, 14% AA)

% of Medicaid births = 40% (2014) – 34% whites, 71% AA

2014 % Change in number from 2003 to 2014 # of Live births % of births Overall 75,104 100%

• 2.4%

White 59,527 79.3

• 6.1%

AA 11,628 15.5 5.5%

Source: MO:DHSS. Vital Statistics; U.S.:CDC, NCHS. National Vital Statistics Reports http://www.cdc.gov/nchs/fastats/infant-health.htm

Infant Mortality Rates (IMR) : MO and US, 2000-2013

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HP 2020: 6.0 per 1,000 MO’s 2014 IMR = 6.1 per 1,000 live births

Source: U.S. data-Infant Mortality Statistics from the 2013 Period Linked Birth/Infant Death Data Set, http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf ; MO data: DHSS vital statistics mortality files.

Leading causes of infant deaths, US and MO, 2013

Source: MO data: DHSS. Vital Statistics http://health.mo.gov/data/mica/MICA/ , U.S. data: CDC, National Vital Statistics System, Mortality Tables. http://www.cdc.gov/nchs/nvss/mortality/lcwk7.htm

IMR by Race, MO and US, 2000-2013

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MO’s 2014 AA IMR = 11.4 MO’s 2014 White IMR = 5.2

Infant Mortality Rates by Cause, Region VIII states, 2008-2010

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Source: Infant Mortality Data Summary Report for Region VII, MCHB / HRSA CoIIN Initiative Meeting, July 2014

2007-11 (MO)

Source: MO:DHSS. Vital Statistics-Birth file

Distribution of live births by race : STL County, STL City, and Missouri, 2014

Source: MO:DHSS. Vital Statistics-Births

Preterm birth by Race, St. Louis County,

• St. Louis City, and Missouri - 2014

Source: MO:DHSS. Vital Statistics- Linked Birth/Death match file

Contribution of preterm births to infant mortality rates, 2005-2014

Source: MO:DHSS. Vital Statistics-Births

IMR by race, St. Louis County, St. Louis City, and MO, 2010-2014

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This is where CoIIN comes into play…

What is CoIIN?

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 A Collaborative Innovation Network (CoIN) is a team of self-

motivated people with a collective vision, enabled by the Web to collaborate in achieving a common goal by sharing ideas, information and work1.

 Key Elements of a CoIN

• Being a “cyber-team” (i.e. most CoIN work will be distance-based);
• Innovation comes through rapid and on-going communication across

all levels;

• Work in patterns characterized by meritocracy, transparency, and
• penness to contributions from everyone.

 Adapted to reflect focus on both innovation and improvement

yielding a Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant Mortality.

 Not exclusive to infant mortality – Home Visiting CoIIN, Injury CoIIN

1 Gloor PA. Swarm Creativity: Competitive Advantage through Collaborative Innovation Networks. New York: Oxford

University Press, 2006.

Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant Mortality – History and Vision

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 HRSA / MCHB Initiative, Voluntary  Partnership among HRSA, ASTHO, AMCHP

, CDC, City Match, CMS, March of Dimes, NGA, NIH and the States

 National Institute for Children’s Health Quality

(NICHQ) – agency responsible for coordinating CoIIN efforts across states, www.nichq.org

 Began in 13 southern states (Region IV and VI) in

January 2012, Region V in March 2013

 Lifespan: 12 – 18 months (rapid cycle improvements)

CoIIN Design

Increase smoking cessation Enhance Interconception Care in Medicaid Reduce elective deliveries <39 weeks Enhance perinatal regionalization Promote safe sleep Co Comm mmon St Strategies for Regi gions IV an and VI VI Te Technical ass ssistance ce Co Contrac act Team; m; sha hared wo work rkspac ace; da data da dashboard rd

State te Team ams

• Title V Directors &

MCH Staff

• State Health

Officials

• Medicaid

Directors & Staff

• Other Partners

(private, local/community, consumer)

Stra rate tegy Team ams

• Leads (2-3

Content Experts)

• Data & Methods

Experts

• MCHB & Partner

Org Staff

• State

Representatives

Launch of Missouri CoIIN

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 In 2014, the Infant Mortality (IM) CoIIN was expanded to the

remaining 31 states and eight territories including Missouri

 July/Aug. 2014: National Roll Out of CoIIN: Regions I-III, VII-X,

and Pacific Islands Infant Mortality Summits. Region VII-July 21-22, 2014 CoIIN Launch Meeting in Arlington, VA

 Pre-Summit Activity # 1 – Infant Mortality Plan – The Agenda states there will

be time built in for each team to work on developing a state infant mortality plan during the summit, which the Missouri team is planning. Due date for this item is June 19th (but this will be done at the Summit.)

 Pre-Summit Activity # 2 – State Infant Mortality Reduction Self-Assessment -

DHSS will develop and circulate a draft of this document and request feedback from the team members via email before the due date. Due date for this item is June 27th.

 Pre-Summit Activity # 3 – Data Systems and Capacity Survey - DHSS will

complete this portion of the report and submit this for the Missouri Team. Due date is June 27th.

 Pre-Summit Activity # 4 – Action Planning Worksheet

Missouri CoIIN Travel Team – July 2014

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Cynthia Dean cdean@mbrcinc.org Chief Executive Officer MBRC Kendra Copanas kcopanas@stl-mcfhc.org Executive Director MCFHC, St. Louis, MO Melinda Sanders Melinda.Sanders@health.mo.gov Title V Director MO DHSS Samar Muzaffar Samar.Muzaffar@dss.mo.gov Medical Director, MO Health Net Division MO DSS Susan McLoughlin smcloughlin@mchc.net Executive Director MCHC, Kansas City, MO Venkata Garikapaty Venkata.Garikapaty@health.mo.g

• v

MCH Epidemiologist MO DHSS Catherine Lewis CLewis1@crmc.org OB Manager, CRMC MHA

MO IM CoIIN – Blueprint for change

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 States had to choose 3-4 strategic priority areas in

that included the following components for the blueprint (September, 2014):

Strategic Priority (3 – 4)

Selected from Infant Mortality CoIIN Framework

Potential Actions (Change Concepts)

Selected from Infant Mortality CoIIN Framework

Outcomes

Anticipated

• utcomes for

each major activity

Lead

Designate team member who is responsib le for driving the action forward Stakeholders/ Resources Identify additional stakeholders and/or resources necessary to implement actions.

Timeli ne

Estimat ed timefra me to start/ end action Infant Mortality CoIIN Framework

MO CoIIN Strategic Priority Areas

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1.

Increase access to and quality of prenatal and maternal care

2.

Enhance access to and quality of care for women before and between pregnancy

3.

Ensure quality of care for newborns/ infants.

NICHQ Letter – Six Topics

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November 18, 2014 “Dear State Infant Mortality CoIIN Teams, Thank you for your patience while the final list of IM CoIIN topics was finalized. We are impressed by how you are forging ahead with your IM CoIIN work. After reviewing the strategy topic areas identified by the expansion states in Regions I-III and VII-X, and the topics that Regions IV and VI identified for their CoIIN re-launch, as well as the CoIIN areas underway in Region V, we noted substantial overlap. In considering this alignment and recognizing that there are limited resources to support CoIINs in Regions IV/VI, Region V and the remaining seven regions, MCHB and the Infant Mortality CoIIN partners believe it would be most efficient and effective to proceed with a new model for CoIIN – a national (rather than regional) approach of 6 CoIIN strategy teams/topics rather than multiple, separate CoIIN strategy teams in Regions IV/VI, Region V and among the expansion states. This will provide states a chance to develop truly national collaboration and to learn from colleagues across the country. (contd..)”

Lauren Smith, MD, MPH Executive Project Director NICHQ (National Institute for Children's Health Quality)

CoIIN – List of final six topics

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 SIDS/SUID/Safe Sleep

 Primary focus is to improve safe sleep practices

 Smoking Cessation

 Primary focus is to reduce smoking before, during and/or

after pregnancy

 Preconception/Interconception Health

 Primary focus is to promote healthy birth spacing and

reduce unintended pregnancy, including focus on Postpartum Visits (content and frequency), Adolescent Well Visits (content and frequency), Long Acting Reversible Contraception (LARC)

CoIIN – List of final six topics

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 Social Determinants of Health

 Primary focus is to incorporate evidence-based

policies/programs and place-based strategies to improve social determinants of health and equity in birth outcomes

 Prevention of preterm and early term births

 Primary focus is to increase appropriate utilization of 17

OH progesterone and/or reduce early elective deliveries.

 Risk appropriate perinatal care (perinatal regionalization)

 Primary focus is to increase the delivery of higher risk

infants and mothers at appropriate level facility.

Missouri CoIIN Priorities

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 Prevention of preterm and early term births

 Primary focus is to increase appropriate utilization of 17

OH progesterone and/or reduce early elective deliveries.

 Risk appropriate perinatal care (perinatal regionalization)

 Primary focus is to increase the delivery of higher risk

infants and mothers at appropriate level facility.

December 19, 2014

HRSA Regions Learning Networks I II III IV V VI VII VIII IX X Total # of States SIDS\SUID Safe Sleep 4 1 5 6 3 3 2 3 3 1 31 Smoking Cessation 3 1 3 3 1 1 4 3 19 Preconception/ Interconception Health 4 2 5 1 3 2 2 3 3 4 30 Social Determinants of Health 4 2 4 3 1 1 3 2 2 22 Prevention of Preterm and Early Term Births 1 2 1 3 1 2 2 4 1 17 Risk Appropriate Perinatal Care (Perinatal Regionalization) 1 1 4 1 1 1 1 1 11

Learning Sessions - Regional Summary

LEGEND Learning = Network Chosen

Prevention of Preterm & Early Term Births n=17

Puerto Rico

MISSOURI

Pre & Early Term Birth Learning Network Aim Statement

 By July 2016 the State of Missouri will reduce the

prevalence of preterm and early term singleton births in Missouri by:

 Decreasing early elective, non-medically indicated

deliveries <39 weeks by 20%

 Reducing late entry into prenatal care by 15%  Increase prevalence of progesterone use in women at

risk for preterm labor.

March 2015

LEGEND Learning = Network Chosen

Perinatal Regionalization n=11

Puerto Rico

MISSOURI Risk Appropriate Care Network Aim Statement

 Increase the % of VLBW (<1500 grams) and

very preterm (<32 weeks gestation) infants delivering at risk-appropriate facilities (Level III w/ NICU) to 90%.

June 2015

Source: MO:DHSS. Vital Statistics-Births

VLBW (<1500 gm) infants delivered at level III facilities, 2005-2014

Levels of Neonatal Care

6th Edition (2007)

• Level I
• Level II A
• Level II B
• Level III A
• Level III B
• Level III C

7th Edition (2012)

• Level I
• Level II
• Level III
• Level IV

Guidelines for Perinatal Care

CoIIN Data Dashboard (CoLaB)

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 CoIIN Wide and Priority specific Measures

CW1: Infant Mortality Rate PT-ETB1:Progesterone Initiation Neonatal Mortality Rate Early Term Birth Postneonatal Mortality Rate Early NMI Elective Delivery SUID Mortality Rate Term Fetal Mortality Rate Preterm related mortality rate RAC – Gestational Age Preterm Births RAC- Birthweight Infant Transfers (<500 gm, 1000- 1499 gm, 1500-1999 gm etc.) CoIIN Wide Measures Priority Specific (by race / ethnicity) (by race / ethnicity) April 2015

Title V MCH Block Grant

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 Established under the Social Security Act of 1935  Nation’s oldest Federal-State partnership  Continues to provide a dynamic program to improve

the health of all mothers and children, including children with special health care needs (30%)

 Each year, all States and jurisdictions are required

to submit an Application/Annual Report for Title V funds

MCH Block Grant Transformation (MCH 3.0)

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 Reduce Burden: Streamline the Annual Report and

Application (20 page summary, reduce the number of forms, redundancies)

 Maintain Flexibility: Apply a Logic Model (six domains,

performance, outcome and structural measures)

 Improve Accountability: New Accountability Framework

(SPRANS Projects, other HRSA programs to move the needle in MCH)

Source: http://www.mchb.hrsa.gov/blockgrant/index.html

Five Year MCH Needs Assessment

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 In addition to the Annual Title V Application, Title V

legislation requires that the State prepare a statewide Needs Assessment every five (5) years that shall identify (consistent with health status goals and National health objectives) the need for:

 preventive and primary care services for all pregnant

women, mothers and infants up to age one;

 preventive and primary care services for all children;

and

 services for children and youth with special health care

needs (CYSHCN)

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Fifteen priority areas across six domains

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NPM # National Performance Priority Areas MCH Population Domains 1 Well woman care Women/Maternal Health 2 Low risk cesarean deliveries Women/Maternal Health 3 Perinatal regionalization Perinatal/Infant Health 4 Breastfeeding Perinatal/Infant Health 5 Safe sleep Perinatal/Infant Health 6 Developmental screening Child Health 7 Injury Child Health and/or Adolescent Health 8 Physical activity Child Health and/or Adolescent Health 9 Bullying Adolescent Health 10 Adolescent well-visit Adolescent Health 11 Medical home Children with Special Health Care Needs 12 Transition Children with Special Health Care Needs 13 Oral health Cross-cutting/Life course 14 Smoking Cross-cutting/Life course 15 Adequate insurance coverage Cross-cutting/Life course

APPENDIX E

MCH Needs Assessment: Core Activities

 Part 1: Qualitative–Stakeholder input (Focus

groups: Consumers, Providers and Agencies)

 Part 2: Quantitative–Epidemiological Analysis of

MCH Indicators

 Part 3: Identification of state MCH priorities

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FOCUS GROUPS

SUMMER 2015 – IN YOUR COMMUNITY

We Want to Know What You Think

Sponsored by the Missouri Department of Health and Senior Services

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Quantitative Indicators – Select Listing

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CYSHCN Associated Measures Barriers for Prenatal Care Childhood Immunizations Adequacy of Prenatal Care Teen (15-17 years) birth rates Health Insurance Status at various stages of pregnancy Teen (15-19 years) birth rate Percent of cesarean deliveries among low-risk first births Mothers breastfeeding their infants at 6 months of age Maternal Mortality Rate per 100,000 Live Births Children without health insurance Women Who Reported Non-back Sleep position for their infants Health care services for children at a FQHC/CHC Rate of Injury-related hospital admissions per population ages 0 through 19 years Suicide deaths among youths (15-19 years) Childhood Immunizations (Series 4:3:1:3:3) VLBW infants delivered at level III facilities Reasons for delays in getting shots for child Smoking among women of childbearing age Health Outcomes/Factors Map Cigarette smoking among high school students Smoking during pregnancy First trimester prenatal care Smoking During Pregnancy on Medicaid Percent of Infants to Women Receiving First Trimester Prenatal Care Oral health among Missouri children (ages 6-9 years) Mothers receiving Adequate Prenatal Care Childhood fatalities due to motor vehicle accidents Postpartum depression Infant Mortality Rate Smoking during the last three months of pregnancy Leading causes of infant deaths Women with a past year preventive visit Infant Mortality Rates by Cause, Race and County Cesarean deliveries among low-risk first births Neonatal mortality rate Infant who are ever breastfed Post-neonatal mortality rate ds who

Ranking of MCH Priorities

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Eight National Priority Areas for Missouri

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Domain – Cross Cutting/Life Course

 Ensure adequate health insurance coverage and improve health

care access for MCH populations – Adequate Insurance Coverage

 Prevent and reduce smoking among women of childbearing age,

pregnant women and reduce childhood exposure to second hand smoke – Household Smoking

Domain – Women/Maternal Health

 Improve preconception, prenatal and postpartum health care

services for women of child bearing age – Well Woman Care

 Improve maternal/newborn health by reducing cesarean deliveries

among low-risk first births – Low Risk Cesarean Deliveries

National Priority Areas for Missouri (cont’d..)

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Domain – Perinatal/Infant Health

 Ensure risk appropriate care for high risk infants to reduce infant

deaths – Perinatal Regionalization Domain – Child Health and/or Adolescent Health

 Reduce intentional and unintentional injuries among children and

adolescents – Child Safety/Injury Domain – Child Health

 Support adequate early childhood development and education –

Developmental Screening Domain – Children with Special Health Care Needs

 Ensure coordinated, comprehensive and ongoing health care services

for children with/without special health care needs – Medical Home

State Priority Areas Chosen by Missouri

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 Enhance breastfeeding initiation and duration rates

among Missouri mothers – Breastfeeding

 Promote safe sleep practices among newborns to

reduce sleep-related infant deaths – Safe Sleep

 Enhance access to oral health care services for MCH

populations – Oral Health

 Reduce obesity among women of childbearing age,

children and adolescents – Physical Activity

 Improve access to mental health care services for

MCH populations – Mental Health

Health Outcomes / Factors Map – County Health Rankings, 2014

Source: 2014 County Health Rankings, http://www.countyhealthrankings.org

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Health Outcomes Health Factors

Different years, same counties..

Source: County Health Rankings, http://www.countyhealthrankings.org

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Summary

• Significant declines in MO’s overall IMR in past

decade, including African-Americans

• Racial disparities in persist – African American babies

are twice more likely to die than whites

• Preterm Births – a significant factor in infant deaths
• CoIIN – a unique public-private partnership
• pportunity to reduce infant mortality and improve

birth outcomes

• Collective Impact: CoIIN, Title V, FLOURISH, Home

Visiting, ECCS, DSS and many more – Coordination?

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Acknowledgements

 MCH Epidemiology Team: Supriya Nelluri, Dr. David McBride,

• Dr. Praveena Ambati, Mary Mosley, Rebecca Chitima, Karen

Harbert, Bryan Angell, Shirley Veit, and Betty Powell

 Division of Community and Public Health (DCPH) – Missouri Title

V Agency

 Section of Epidemiology for Public Health Practice – Office of

Epidemiology, Bureau of Vital Statistics, Bureau of Health Care Analysis and Data Dissemination

 Section for Special Health Services, Section for Healthy Families

& Youth

 State Systems Development Initiative (SSDI), CDC PRAMS

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Email: Venkata.Garikapaty@health.mo.gov Phone: 573-526-0452