1. Teaching prenatal care through group visits: learning from experience Jessica Gamboa MS3, Jordan White MD, Sara Shields MD MS, Susanna Magee MD MPH Alpert Medical School of Brown University University of Massachusetts

2. Objectives Discuss the state of prenatal care in Family Medicine today Describe how prenatal care is taught in residency Describe Brown’s Group Prenatal Care Intervention Describe UMass’ Group Prenatal Care Intervention Future implications

3. Changing Practice Patterns In 2010, 83% reported their reason as “Not Desired”. 1 1) American Academy of Family Physicians, Practice Profile I Survey

4. A.U.S. PCHPSAs by county, 2006 B.U.S. PCHPSAs by county after withdrawal of family physicians (PCHPSA = primary care health professional shortage area) Map prepared by the Robert Graham Center, Policy Studies in Family Medicine and Primary Care, Washington, D.C., with data from the Health Resources and Services Administration (August 3, 2006)

5. How can we encourage residents to include prenatal and obstetrics care? UNC, 2003 2 Family practice model of prenatal/obstetrics care Separate service from OB All deliveries supervised by family medicine faculty Emphasis on continuity and child health care after delivery Inc number of graduates practicing prenatal care after graduation Beth Israel, 2009 3 Centering Pregnancy® group Improved resident’s comfort in prenatal care and deliveries Residents found work fun and energizing again 2) Helton, 2003 3) Beth Israel, 2009 2006-20072007-20082008-2009 Prenatal women 95111141 Deliveries8494111* Group numbers 52251

6. Why group care? Successfully implemented in over 100 sites 4 Increased patient-provider time Facilitative vs. didactic teaching Patient-centered care Associated with positive outcomes Increased birth weight Increased gestational age at delivery Increased rate of breastfeeding Better satisfaction with care 4) Baldwin, 2006

7. How can residents benefit from group care? Increase fund of knowledge on basic prenatal care topics Learn common concerns and questions during pregnancy Improve confidence in caring for prenatal women Provide more opportunities for practicing prenatal care

8. Teaching Prenatal Care Traditional 5 1 Family Medicine faculty competent in maternity care to supervise and serve as a role model Traditional doctor patient relationship Provider gives information and patient accepts it No direct observation of entire prenatal visit required Group prenatal care 1 Family Medicine faculty competent in maternity care to supervise and serve as a role model Cover basic prenatal care topics with a team approach Resident acts as facilitator in group discussions Each visit is supervised by Family Medicine faculty passionate about maternity care Real time feedback after each prenatal visit for the resident/learner 5) ACGME Program Requirements for Graduate Medical Education in Family Medicine. effective July 2007

9. Why Here? Compared with other communities in the RI area, Memorial Hospital serves communities with a high incidence of poor perinatal outcomes 6 6) www.rikidscount.org Perinatal Outcomes Central Falls/ Pawtucket National Preterm Birth12% Low Birth Weight6-8.5%8.2% Initiation of Breastfeeding 43-51%67%

10. Brown’s Pilot Program 3 Family Medicine resident facilitators- (2)PGY-1 and (1) PGY-2 Women recruited by residents, nurses and faculty with posters/brochures placed in waiting rooms Attempts to recruit 8-10 women Age 18+ Similar gestational ages at presentation Goal: diversity in terms of racial and ethnic background, G/P, family dynamic, etc. Supported by one faculty member trained in Maternal Child Health, one fellow in Preventive Medicine and third year medical student.

11. Brown’s Pilot Program Of 5 women agreeing to participate, 4 women participated Ages 21-33 GA at first visit from 12-28 weeks G1P0 to G5P4 2 women included their partners in the group

12. Brown’s Pilot Program 5 monthly sessions, supplemented by individual visits with their PCP Residents rotated as the facilitator for group discussion on various topics Diet, exercise, common complaints of pregnancy, infant care, and labor/pain management Preparation for group visits and follow up visits scheduled by Dr. White as well as monthly chart review

13. Qualitative Outcomes for Patients “I enjoyed meeting other women and especially hearing from experienced moms.” “I liked getting to bond and get to know my doctors.” “I am grateful for all if have learned and shared.” “Centering is a good idea and very helpful. I feel they should continue to have more groups in the hospital.”

14. Quantitative Outcomes for Patients

15. Qualitative Outcomes for Residents “I learned so much more about prenatal care based on the preparation that was done for group visits” “Each prenatal patient grew to know each prenatal provider to the degree that they were comfortable with any/all of us in the delivery room.” “I liked having the ability to learn how my colleagues counsel regarding prenatal issues and getting to know the women in the context of the group.” “Individual visits often feel so rushed and there is little time to talk about less critical issues. With group care this was never a problem.”

16. Quantitative Outcomes for Residents

17. Challenges & Potential Solutions Difficulty recruiting patients Schedule conflicts with residents on different services Lack of appropriate space for sessions Lack of dedicated nursing personnel/MA Lack of dedicated time Staff exposure to group care Buy-in from management and administration Grants for increased personnel Patient Centered Medical Home

18. UMass Experiences Inner city community health center (330 funded) Central Massachusetts Family medicine model Residency training site About 75% public insurance Multi-cultural and multilingual Worcester Healthy Start Initiative On-site WIC program About 300 births annually

19. FHCW Residents and Students 2007-8: 2 residents, co- facilitators Used health center time; no training 2008-9 1 non FHCW resident, elective time 2 FHCW residents, health center time 1 first year medical student Training: 4 residents (grant-funded) 2009-10 2 non FHCW residents, elective time 1 second year medical student (same one) 2010-present 3 FHCW residents, health center time 1 preventive medicine fellow 1 first year medical student

20. FHCW and Group Care Small and medium-sized grants Staff support—using existing advocates Buy-in from faculty/staff Data! Get them to try it! Other groups with longevity (diabetes) Champions (CNM, NP, MD) Ongoing: retention, space, scheduling Square peg in round hole Data and budgeting

21. 2009-2010 at FHCW 101 women in groups 69% nulliparous (70) 65% non-US born 22% teens (<20yrs) 1 LBW infant (1%) 56% exclusive breastfeeding at immediate visit 551 women traditional 66% multiparous 63% nonUS born 13% teens (<20yrs) 26 LBW infants (4.7%) 2010 only: 41% exclusive breastfeeding at immediate visit

22. The Future Can group prenatal care be a tool to increase the number of graduating residents including prenatal care in their practice? Comfort Knowledge Empowerment Experience

23. Acknowledgements Women’s Reproductive Health Freedom and Rights Scholarly Concentration and the Braufman Fund at Brown University

24. References ACGME Program Requirements for Graduate Medical Education in Family Medicine. effective July 2007 Baldwin, Karen Comparison of Selected Outcomes of Centering Pregnancy versus Traditional Prenatal Care Journal of Midwifery and Women’s Health 51 (2006): 266-272 Barr, Wendy Using Centering Pregnancy to Teach Prenatal Care: Implementing Group Prenatal Care in a Family Medicine Residency. Beth Israel Residency in Urban Family Medicine presentation: 2009 Dresden, Graham et al Influence of Obstetrics Practice on Workload and Practice Patterns of Family Medicine Physicians and Obstetrician-Gynecologists Ann Fam Med 2008; 6(suppl 1): s5-s11 Helton, Margaret MD et al A Maternal and Child Health Curriculum for Family Practice Residents: Results of an Intervention at University of North Carolina Fam Med 2003; 35(3): 174-180 Robert Graham Center, Policy Studies in Family Medicine and Primary Care, Washington, D.C., with data from the Health Resources and Services Administration (August 3, 2006) Ringdahl, Erika MD et al Changing Practice Patterns of Family Medicine Graduates: A Comparison of Alumni Surveys from 1998-2004 J Am Board FM 2006; 19:404-412 Rhode Island Kids Count http://www.rikidscount.orghttp://www.rikidscount.org

25. Questions?