Welcome! MOMS Plus Project Action Period Call

Transcription

1 Welcome! MOMS Plus Project Action Period Call Ohio Perinatal Quality Collaborative January 18, 2019 Through collaborative use of improvement science methods, reduce preterm births & improve perinatal and preterm newborn outcomes in Ohio as quickly as possible.

2 Welcome to the OPQC MOMS Plus Action Period Webinar OPQC is using new software (Zoom) for Action Period Calls. Please sign in the chat box with the names of all webinar participants AND your hospital/ob practice affiliation or organization. Please be certain you are on mute when not speaking to avoid background noise. You can mute/unmute yourself by clicking the Mute icon at the bottom of the screen or by pressing *6 on your phone. 2

3 helpful tips: If your phone connection drops during the webinar simply click on Join Audio (left hand corner of the bottom ribbon) to be automatically reconnected Send questions/comments to the chat box if unable to come off mute/in a noisy area 3

4 Agenda Time Topic Presenter 12:00 pm Welcome & Agenda Review Susan Ford, MSN, RN 12:05 pm Overview of the past months Susan Ford 12:10 pm Hepatitis C in the Pregnant Patient with Opioid Use Disorder Mona Prasad, DO, MPH 12:40 pm Data Updates Susan Ford 12:50 pm Next Steps Susan Ford 4

5 MOMS+ Project Key Driver Diagram (KDD) Global Aim SMART Aim By June 30, 2019 we will: Optimize maternity medical home to improve outcomes for pregnant women with opioid use disorder (OUD) as measured by: Increased identification of pregnant women with OUD Project Leader: Carole Lannon (PI) Optimize the health and well-being of pregnant women with opioid use disorder and their infants Increased % of women with OUD during pregnancy who receive prenatal care (PNC), Medication Assisted Treatment (MAT) and Behavioral Health (BH) counseling each month Decreased % of full-term infants with Neonatal Abstinence Syndrome (NAS) requiring pharmacological treatment Increased % of babies who go home with mother Population Pregnant women with opioid use disorder Key Drivers Timely identification and tracking of pregnant women with opioid use disorders Compassionate and coordinated care Empowerment of women through community based services Supported mother/infant dyad post delivery Interventions Revision Date: 5/21/2018 Complete a standardized screening tool on each patient to accurately identify and diagnose pregnant women with OUD (e.g. 5 P s, NIDA Quick Screen). Establish a coordinated referral system with BH providers, MAT providers, drug courts, prisons, homeless shelters, and ERs. Utilize a tracking system (e.g.. Database, spreadsheet) to follow pregnant women with OUD history/diagnosis and all babies with prenatal opiate exposure. Check OARRS per prescribing protocols. Complete training in trauma informed care and addiction as a chronic illness to provide nonjudgmental support for pregnant women with OUD Designate a care coordinator to arrange referrals and ongoing communication between the trans-disciplinary care team. Provide immediate support/counseling at time of identification by OB/FP by using standardized interviewing techniques. Implement a process to prevent acute opiate withdrawal by initiating MAT Implement a standardized process for referral to appropriate/necessary resources for women with a positive screen for OUD. Coordinate care between OB, BH, MAT, NICU/Pediatrics by regularly reviewing shared patients (e.g. multi-disciplinary care conference, huddle). Tailor counseling and support for healthy behaviors based on patient-specific situation/need during pregnancy (sobriety, smoking cessation, stable housing and birth spacing (LARC)), with referral to community resources as needed to augment medical resources. Consider implementing or referral to OUD specific Centering Pregnancy program Connect women to vocational training opportunities as applicable Involve community partners including referrals to faith-based organizations to support pregnant women with OUD (e.g. support groups, shelters, food pantries, etc.) Coordinate Prenatal consultation for pregnant women with OUD with Neonatology/Pediatrics to discuss Neonatal Abstinence Syndrome (NAS) Ensure mom and baby have a Patient Centered Medical Home (post-delivery) Provide a warm handoff to pediatric care provider for infant post discharge (e.g. call/consultation and newborn/maternal summary) Provide lactation consultation (if applicable), post partum depression screening and contraceptive counseling Prenatal referral for pregnant women with OUD to Community Health Workers and/or home visitation programs (dependent on region) Postnatal referral or consideration to Help Me Grow and/or parenting classes Facilitate continuation and retention of OUD treatment and services during pregnancy and post-delivery occur (e.g. support of ongoing MAT maintenance services, training care providers to recognize signs of relapse and that mom is continuing in her treatment program) Coordinate with Department of Job & Family Services/Child Protective Services regarding reporting requirements and infant plan of safe care

6 Oct AP Call: Screening Tools for OUD November Learning Session in Columbus Progress to date Dec AP Call: Post partum Pain Management January 2019: Data entry opens for teams with submitted DUA/BAA! Jan AP Call: Hepatitis C Screening, Diagnosis and Management Sept AP Call: Initial encounter management July AP Call: Regional collaboration Aug AP Call: Collaboration with MCP/use of PRAF 2.0 May-June 2018 Kick off six regional meetings February 2019: Follow up coaching calls with teams 6

7 Maternal HCV infection rates in Ohio by county 7

8 Hepatitis C screening, diagnosis and management: a unique problem for pregnant women with OUD Mona Prasad, DO, MPH Assistant Director, Perinatal Services Grant Medical Center, OhioHealth Columbus, OH 8

9 Goals Review the Epidemiology of HCV Discuss Screening for HCV Discuss vertical transmission of HCV Review current practice guidelines in managing pregnant patients with HCV Discuss Direct Acting Antivirals (DAAs)and how this may change current practices Stir conversation 9

10 Hepatitis C Virus The non-a, non-b factor 10

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14 Hepatitis C: Epidemiology Seroprevalence among certain populations 15-50% among homeless, incarcerated people 70-90% among IVDA, hemophiliacs treated with blood products before 1992 Migration from endemic areas: higher prevalence in Asia, Middle East, Africa, and Southern and Eastern Europe 14

15 Hepatitis C: Epidemiology Chronic Infection in 60% of patients Leading cause of cirrhosis: in 20% of chronically infected patients Common Cause of Hepatocellular Carcinoma: at a rate of 1-4% /year in those patients with Cirrhosis Leading cause of liver transplant in the US NIH Consensus Statement on Management of Hepatitis C: 2002; 19(3):

16 Hepatitis C: Epidemiology Pediatric Hep C HCV seroprevalence 0.2%-0.4% 68, ,000 chronically infected children in the US Prior to 1992, most common mode of acquisition was via blood products Currently almost all new cases are acquired via vertical transmission Rumbo, C. Hepatitis C: Current approaches in pediatrics. Pediatric Transplantation 2005; 9:

17 Hepatitis C: Epidemiology Pediatric Hep C Disease spectrum varies greatly in children as well Generally milder course Lack of coexisting risk factors for progression Many cases of aggressive disease leading to hepatocellular carcinoma in adolescents or resulting in cirrhosis and liver transplant 17

18 HCV Vertical Transmission Epidemiology US Birth Cohort: 4 million births/year 99% Mothers HCV Seronegative 1% Mothers HCV Seropositive* 40,000 births/year 66% Mothers HCV-RNA Positive* 24,000 births/year 33% Mothers HCV RNA Negative* 5% Vertical Transmission 1,200 births/year 95% No Transmission 23,800 births/year ~100% No Transmission *Jhaveri et al. J Pediatr 2006;148:353 Mast et al. JID 2005;192:

19 Hepatitis C: Epidemiology 19

20 Hepatitis C: The Virus 20

21 Hepatitis C: Screening 21

22 Hepatitis C: Screening Fundamentals of a Screening Test To test an asymptomatic group an apply a probability of likelihood of developing disease Goal: Reduction in incidence, recurrence or severity of disease MUST HAVEs Serious consequences if untreated High enough prevalence to make screening effective Effective treatment available Cheap Highly sensitive 22

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24 Hepatitis C: Screening Patients for whom HCV screening is uncertain Recipients of Tissue Transplants Users of intranasal cocaine or other illegal noninjected drugs Persons with a history of tattoos or body piercing Persons with a history of STDs or multiple sexual partners* Long-term steady sex partner of and HCV-infected person 24

25 Hepatitis C: Screening ACOG/SMFM currently do not recommend routine Hep C screening in pregnancy ACOG acknowledges that the primary risk factors are the same for Hep B and Hep C The CDC and AASLD are currently endorsing universal screening in pregnancy 25

26 HCV Screening and Diagnosis 26

27 HCV Screening and Diagnosis 27

28 Hepatitis C: Vertical Transmission 28

29 Hepatitis C: Vertical Transmission ACOG cites 7-8% vertical transmission rate Coinfection with HIV increases to 15% No prenatal intervention has been reported to reduce vertical transmission 29

30 Risk Factors Hepatitis C: Vertical Transmission Maternal Viral Load Exposure to maternal blood Duration of ROM Internal Monitoring 30

31 Hepatitis C: Vertical Transmission SOUND FAMILIAR? 31

32 Hepatitis C: Vertical Transmission With HIV positive women: Timing of transmission has been established by presence versus absence of viral RNA at the time of delivery This is widely accepted for HIV and the notion has been similarly applied to Hepatitis C, but has not been established Newell M-L, AIDS 1998, 12:

33 Hepatitis C: Current Practice Patterns among OB/GYNs ACOG does not recommend any intervention to prevent vertical transmission 33

34 Hepatitis C: Current Practice Patterns Why don t we use prophylactic cesarean delivery? Plunkett and Grobman, AJOG 2004 estimate that 18 elective cesarean deliveries necessary to prevent one neonatal infection Transmission rate is presumably low For this to be cost effective: we need to show a 77% reduction in risk of perinatal transmission 34

35 Hepatitis C: Current Practice Patterns Gibb, et al Lancet 2000 Mode of Delivery 339 Underwent Vaginal: 7.7% vertical transmission rate 54 Underwent Emergency Cesarean: 5.9% vertical transmission rate 31 Underwent Elective Cesarean: 0% vertical transmission rate 35

36 A Significant Sex but Not Elective Cesarean Section Effect on Mother-to-Child Transmission of Hepatitis C Virus Infection No protective effect of elective cesarean delivery on HCV vertical transmission OR 1.46 (95% CI , p=0.16) 36

37 Hepatitis C: Current Practice Patterns Why don t we use prophylactic cesarean delivery? There is a current lack of evidence Studies limited by low numbers Studies limited by including coinfection with HIV in the analysis 37

38 Hepatitis C: Current Practice Patterns Cochrane Database Review, October 2006 Currently there is no evidence from randomised controlled trials upon which to base any practice recommendations regarding planned caesarean section versus vaginal delivery for preventing mother to infant Hepatitis C Virus transmission. 38

39 Hepatitis C: Breastfeeding 39

40 Hepatitis C: Breastfeeding The CDC/AAP and ACOG endorse breastfeeding Unless HIV coinfection Watch for risks like cracked/bleeding nipples Until recently an area of controversy 40

41 Hepatitis C: New Medical Therapies 41

42 Hepatitis C: New Medical Therapies The approach to hepatitis C patients in pregnancy may change with emerging drug therapies 42

43 Hepatitis C: New Drug Therapies Protease Inhibitors Polymerase inhibitors 43

44 Hepatitis C: New Medical Therapies DAAs Direct Acting Antivirals 2011 Victrelis (boceprivir), Incivek (telapravir) 2013 Olysio (Simepravir), Sovaldi (Sofosbuvir) 2014 Harvoni (ledipasvir/sofosbuvir) 2016 Zepatier (Elbasvir/grazoprevir), Epclusa (Sofosubuvir/velpatasvir) 44

45 hcvguidelines.org 45

46 Conclusions Hepatitis C is an important public health problem More aggressive approach to screening may identify even more significant problem in pregnant populations 46

47 Conclusions Risk Factors for vertical transmission of Hepatitis C include: Viremia, exposure to maternal blood, duration of rupture of membranes, internal fetal monitoring In spite of parallels that can be drawn between HIV and Hepatitis C in pregnancy, there are currently no specific treatment guidelines for the care of pregnant patient with Hepatitis C 47

48 Conclusions Breastfeeding was historically a controversial topic, but ACOG and AAP have recommended breastfeeding for Hepatitis C positive women DAA treatment may change our approach to treatment of Hepatitis C during pregnancy 48

49 Hepatitis C Treatment Coverage Effective 1/1/2019, the Ohio Department of Medicaid joins a number of other states in addressing escalating Hepatitis C infections by treating all chronic Hepatitis C patients regardless of their fibrosis scores. Treatment of patients with HCV at stage F0 supports ODM s efforts to pay for value in health care, contributing to solutions to address the harms created by the opioid epidemic and aligning with Ohio Department of Health population initiatives to lower viral transmission.» Goal: Eradicating Hepatitis C in whole communities. Direct-acting antivirals (DAA s) are more accessible than ever as the cost has been decreasing due to both competition and market-shifting, offering opportunities through the MCPs and FFS Medicaid. All Ohio Medicaid MCPs and FFS follow the same clinical criteria for coverage of DAA s 49

50 Example Checklist top Optimize Prenatal Care for Women with OUD, Chart Template Stealing shamelessly from the Northern New England Perinatal Quality Improvement Network 50

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52 Suggested PDSA What percentage of your patients are screened for HCV? Should be 100%. Would implementation of the an HCV component of the clinical checklist increase that? What percentage are eligible for linkage to care? What percentage have linkage established for postpartum treatment prior to delivery? 52

53 Questions/Discussion 53

54 Data Updates THANK YOU to the teams that have submitted their Data Use Agreements (DUA) and Business Associate Agreements (BAA) Required from each participating hospital/ob Clinic MAT Provider BH Provider Participating in an OPQC Project and Exchanging Data with OPQC: OPQC Amended and Restated Participation Agreement: this is a legal agreement about participating in an OPQC project that needs to be signed and returned to OPQC Central MOMS+ Project Addendum + Business Associate Agreement: this is the specific addendum to the participation agreement about the MOMS+ project PLUS the Business Associate Agreement that needs to be signed and returned to OPQC Central 54

55 ODM Standard Authorization Form, Instructions and Fact Sheet ~posted on OPQC MOMS Plus SharePoint site~

56 DATABASE TRAINING FOR THE MOMS+ REGISTRY FOR PRENATAL CARE PROVIDERS Contents: Access and Logging into the Registry Home Page Orientation Important First Steps & Provider Management Functions Registration of a New Patient Patient Enrollment Data Entry Patient Dashboard Features Data Collection Forms and Ownership Follow-up Visit Data Entry Updating MAT or BH Clinic Information MOMS+ Registry Help Additional guidance can be found in the MOMS+ Data Entry Users Manual found on the SharePoint Site: 56

57 Next Steps MOMS Plus Project Please submit your site s DUA and BAA forms to OPQC! PDSA: Investigate what percentage of your patients are screened for HCV. Consider testing the HCV component of a clinical checklist if not at 100%. The MOMS+ February Action Period Call will be Friday, February 8 th at 12N Key Contacts: Review/submit Monthly Progress Report; January MPR will be sent out next week Schedule your team s coaching call Consider attending one of the MOMS Plus Data Entry Office Hour webinars Monday, January 28 th 12N-1pm Friday, February 15 th 8am-9am Wednesday, February 20 th 12N-1pm 57

58 It takes a village The MOMS+ Project is funded by the Medicaid Technical Assistance and Policy Program (MEDTAPP) and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in this meeting are solely those of the authors and do not represent the views of state or federal Medicaid programs.