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Maine Prenatal Collaborative. Principal Investigator Project Director Data Analyst. Susan Swartz, M.D. Judy Soper, RT(R), RDMS, BS Tim Cowan, MSPH. December 11, 2003 National Conference on Tobacco or Health. Tobacco and Pregnancy in Maine. ~ 1 in 5 pregnant women 38% on Medicaid.

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Maine prenatal collaborative l.jpg

Maine Prenatal Collaborative

Principal Investigator

Project Director

Data Analyst

Susan Swartz, M.D.

Judy Soper, RT(R), RDMS, BS

Tim Cowan, MSPH

December 11, 2003

National Conference on Tobacco or Health

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Tobacco and Pregnancy in Maine

  • ~ 1 in 5 pregnant women

  • 38% on Medicaid

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Target Provider Population

  • Prenatal Care Providers

    • Obstetricians

    • Family Practitioners

    • Nurse Midwives

  • And members of their teams

    • Clinical support staff

    • Office staff

    • Manager

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Intervention Model

  • Clinical Collaborative

    • Institute for Healthcare Improvement


  • Chronic Care Model

    • Improving Chronic Illness Care


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What is the Collaborative?

Bringing practices together to improve systems of care and patient outcomes

Our goal: To enhance interventions with pregnant smokers

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LS = Learning Session

AP = Action Period



Collaborative Learning Model


Continued Spread


LS 1

AP 1

LS 2

AP 1

LS 3

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Learning Sessions

  • Expert knowledge in areas such as

    • Tobacco in pregnancy

    • Motivational interviewing

    • The 5 A’s

    • Pharmacotherapy

  • Workshops

    • Setting aims and goals

    • Using the change cycle process

    • Monitoring improvement

  • Learning from each other

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Action Periods

  • Testing changes

  • Monitoring improvement

  • Conference Calls

  • Site visits

  • Assistance and support as needed

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Chronic Care* Model

Health System

Decision Support

Clinical Information Systems

Self-Management Support

Delivery System Design


Informed, Activated Patient

Prepared Practice Team

Productive Interactions

Functional and Clinical Outcomes

* The Care Modelwas developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues support from the Robert Wood Johnson Foundation.

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Small Tests of Change The PDSA Road Map

Develop Your Roadmap:

Identify the change you want

to try, and a plan for

testing it.

Run The Course:

Take the steps that have been planned to make the desired change.





Review Your Progress:

Look at the data you gathered. Evaluate if the change you tried

has worked.

Choose Your Path:

Are the results what you want? If yes, implement the change. If no, move to a new idea.

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Data Collection

  • Tobacco Treatment Flow Sheet

  • Manual

  • Electronic Medical Record

  • Tobacco Treatment Database

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Tobacco Treatment Database

Option 1:

Place the Tobacco Treatment Flow Sheet in a folder for end of month review.

Option 2:

Keep the original Tobacco Treatment Flow Sheet in the patient chart and place a copy in the folder for

end of month review.

Complete Tobacco Treatment Flow Sheet for all patients.

Gather Information for Reporting:

1. Generate the established reports in the database for at risk patients.

2. Count the number Tobacco Treatment Flow Sheets of non-smoking patientsin the folder.

3. Determine the total pregnant patient population, using your billing or internal system.

Enter numbers generated from steps above into the Access database

Place a sticker in or on the chart to indicate status.


Enter visit information into the database.

At Risk

Not At


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Run Chart Example

  • Patients with documented tobacco status

  • At risk patients receiving advice

  • Current smokers assessed for interest in quitting

  • At risk patients who received assistance during at least one visit

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Project Evaluation - Office System

  • Practice inventory

    Observational assessment of the office practice and clinical site. Baseline/1 year.

  • Tobacco Related Documentation

    Chart audit assessment. Baseline/1 year.

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Project Evaluation - Office System (continued)

  • Proactive HelpLine Referral

    Use of Every Mother’s Wish proactive referral form. Baseline/1 year.

  • Medicaid Reimbursement Use

    Utilization of add-on code for brief tobacco intervention. Baseline/1 year.

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Project Evaluation - Provider/Staff Behavior

  • ACIC - Assessment of Chronic Illness Care

    • Conducted individually

      • all team members

    • Modified for tobacco in pregnancy

    • Baseline/1 year

  • Individual Survey - Clinician Behavior/Beliefs

    • Conducted individually

      • all clinical team members

      • additional practice providers and clinical support staff

    • Baseline/1 year

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Project Evaluation - Collaborative Process/Feasibility

  • Qualitative Evaluation

    Beliefs, needs, expectations, themes.

    Baseline/During/1 year.

  • Team Benchmarking

    Goal setting, measures, data collection, monthly reporting, degree of improvement.

    Monthly during Collaborative.

  • Team Satisfaction

    Learning sessions, materials, Collaborative staff resources, conference calls, tools, etc.

    Each Learning Session.

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Project Evaluation (continued)- Collaborative Process/Feasibility

  • Team Participation

    Learning sessions, conference calls, monthly reporting.

    Monthly during Collaborative.

  • Team Function

    Team member evaluation, roles responsibilities, leadership identification, tool use, data collection.

    Baseline/1 year.

  • Practice Change

    Self reported change in knowledge, confidence, resource use, etc.

    1 year.

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Project Evaluation -Tobacco Treatment

  • Tobacco Treatment Database

    • Number of pregnant patients with tobacco status documented

  • never

  • quit more than 12 months

  • quit less than 12 months

  • quit during pregnancy

  • current smoker

  • Number of at risk patients given advice

  • Number of current smokers assessed for interest in quitting

  • Number of at risk patients given assistance

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  • Tobacco Treatment Flow Sheet

  • Tobacco Treatment Database

  • Quick Clinician Guide

  • Modified collaborative model specific to tobacco in pregnancy

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Lessons Learned and Recommendations

  • Recruitment less challenging that anticipated

    • Be prepared

    • Provide information relevant to the practice

    • Ask them about their interests/goals

  • Time, time, time - the evil barrier to all.

    • Be realistic and flexible

  • Jargon is a time bomb!

    • Remove as much as possible - keep the information straightforward

  • People genuinely want to do well

    • Be realistic with expectations