IHN-CCO DST Final Report and Evaluation

Transcription

1 IHN-CCO DST Final Report and Evaluation Breastfeeding Support Services July 2016 to September 2018 Summary: This pilot reduced the barriers new mothers have in being able to successfully breastfeed their children through the placement of a Spanish speaking International Board-Certified Lactation Consultant (IBCLC) in the Samaritan Mid-Valley Pediatric office in Lebanon and by expanding breastfeeding support services in Linn County Women, Infant, and Children (WIC) clinics. By the placement of a Lactation Consultant in the clinic setting, evaluation and consultation to the motherbaby is provided in coordination with the other medical services delivered by primary care staff. An IBCLC's contribution to the care of the new breastfeeding family meets the American Academy of Pediatrics recommendations that breastfed babies be seen within 3 to 5 days of birth. A. Budget: Total amount of pilot funds used: $125, Please list and describe any additional funds used to support the pilot. None B. Provide a brief summary of the goals, measures, activities, and results and complete the grid below. A Spanish speaking IBCLC was placed in the Samaritan Lebanon Health Center pediatric office 2 days each week. She saw over 510 client consultations between December 2016 and September Collaborating with other IBCLCs she participated in starting two breastfeeding support groups: a monthly group for WIC clients, and a weekly group at the hospital to offer drop-in breastfeeding help to Linn County families in the Lebanon/Sweet Home area. She taught a 6 hour breastfeeding class to public health nurses from Linn, Benton and Lincoln Counties, and presented at the 2018 Innovation Café. She and the other IBCLC participated in meetings resulting in lactation licensure passing and both are now licensed in the state of Oregon. Both IBCLCs met with the provider reimbursement coordinator at Samaritan Health Plans on October 3 and a plan is now in place to begin billing for this service 1/1/2019. Goal Measure(s) Activities Final Results Maintain exclusive breastfeeding Use of infant formula in first 1-6 days of life IBCLC has provided over 510 client consultations and has collected data about breastfeeding rates. Appointment schedules See attached data sheet. Maintain exclusive breastfeeding Use of infant formula at 2 months of age have remained full. IBCLC has provided over 510 client consultations and has collected data about breastfeeding rates. Appointment schedules have remained full. See attached data sheet. Babies who saw the grantfunded IBCLC (alone or in combination with other lactation consultants) after discharge were more likely to be exclusively breastfed at their 2-month appointment (66%; t(330) = 2.290, p =.023) than babies who did not see her (49%). Logistic regression analyses examining the relationship

2 IHN-CCO DST Final Report and Evaluation Increase number of breastfeeding women seen by an IBCLC for lactation counseling Increase number of IHN- CCO members receiving lactation support services in Samaritan Mid Valley Pediatrics clinic Achieve PCP satisfaction with lactation support services in Samaritan Mid Valley Pediatrics clinic Number of referrals made to IBCLC by PCP Number of IHN-CCO members receiving lactation support services in Samaritan Mid Valley Pediatrics clinic PCP feedback on lactation support services The pediatric providers refer to the IBCLC, and sometimes call the IBCLC in to meet with their patients. Accurate data is difficult to collect given the nature of our scheduling system. Samaritan Mid Valley Pediatric Clinic IBCLC services continue to be promoted to all WIC clients seen in Linn County as well as all breastfeeding patients of Samaritan Lebanon Health Center Pediatrics clinic. Posters are also displayed in the Lebanon pediatric and obstetric offices. IBCLC continues to send staff messages to providers when she sees their patients, and providers normally respond with a thank you or a brief comment. between seeing the grantfunded IBCLC after discharge and exclusive breastfeeding showed that seeing the grant-funded IBCLC is a statistically significant predictor of exclusive breastfeeding at the 2-month appointment but not at the newborn appointment. In 2016 there were 3 known referrals from providers to the IBCLC. In 2017 there were 35 and in 2018 there were 12. There were likely very many more than this though. Any time a provider or mother called to get on the schedule for lactation help, if the mother was already on WIC or was eligible for WIC, the appointment was scheduled as a WIC appointment, so it was not possible to track how many appointments were truly due to referrals. From December 2016 through September lactation appointments were provided to IHN-CCO members through this grant. Over 510 client consultations were provided altogether. Comments from September 2018 survey include I love it when she can see patients the same day. Parents think she is great. Often when she is in clinic we will send a

3 IHN-CCO DST Final Report and Evaluation Participate in the progress toward IBCLC licensure and insurance reimbursement for lactation services Contracts with IHN-CCO and Oregon Health Authority (OHA) leadership regarding lactation support as a covered benefit IBCLCs are in contact with the provider reimbursement coordinator at Samaritan Health Plans and working towards becoming credentialed providers. warm handoff to her and she is able to resolve issues on same day. All the providers said in a March 2018 meeting that they would like to see this service continue. Both IBCLCs are licensed. Both IBCLCs are set to begin billing IHN-CCO 1/1/2019 C. What were the most important outcomes of the pilot? Over 510 clients received lactation and/or WIC services in the Samaritan Lebanon Health Center. A monthly breastfeeding support group ( Breastfeeding Circle ) began in June continues to be facilitated by one IBCLC. Numbers of mothers reached have increased from 2 at the first meeting to 8+ at the most recent ones. The grant-funded IBCLC is collaborating with Lebanon Hospital IBCLC to provide a weekly support group for breastfeeding mothers to offer weight checks and basic breastfeeding support on a drop-in basis. This weekly support group reaches 1-5 families each week for weight checks and breastfeeding support. IBCLCs are in continuing contact with staff at the state WIC office and the local level about how IBCLCs billing may work in the context of public health and WIC, and about getting lactation consultants credentialed so their services can be reimbursed by OHP, IHN-CCO and private insurance. Credentialing process with IHN- CCO has begun. Other insurance providers will be added in the future. D. How has the pilot contributed to Triple Aim of improving health; increasing quality, reliability, and availability of care; and lowering or containing the cost of care? Longer duration of breastfeeding has been shown to improve health outcomes for mothers and babies. Although our data did not show a statistically significant increase in breastfeeding rates or duration at this clinic overall, babies who saw the grant-funded IBCLC were more likely to be exclusively breastfeeding at their two month appointment than babies who did not see her. Having this service available in the clinic has made lactation support more available because parents are already familiar with the location, and many have been able to have same-day lactation support when a pediatric visit revealed breastfeeding issues. Before this position was created, there were lactation appointments available 2 days each week in Lebanon with the IBCLC at the hospital. By adding the grant-funded IBCLC 2 days each week, the availability of lactation was doubled to 4 days each week. This has meant that families needing lactation support are more likely to be able to get an appointment in a timely manner. The weekly drop-in breastfeeding support group has increased the availability of lactation support to families who may not have issues requiring a full lactation appointment. Many families benefit from weight checks and brief support and encouragement from IBCLCs. This group has increased the quality and availability of lactation care. Much of the time spend in pediatric appointments in the first month of life is spend discussing breastfeeding issues. Full assessment and support of these issues is time consuming and can be done by an IBCLC, rather

4 IHN-CCO DST Final Report and Evaluation than a physician. Having a dedicated lactation appointment with an IBCLC improves the patient experience and reduces physician time spent on these issues, which is also a savings to cost of care. E. What has been most successful? Collaboration between WIC and pediatric providers has increased Two breastfeeding support groups have been created to provide support for breastfeeding families Lactation licensure passed in Oregon and is now required for all non-rn IBCLCs We are about to begin billing for this position and making it sustainable. F. Were there barriers to success? How were they addressed? In the beginning, communication between providers and the IBCLC was difficult because providers were not flagged when the IBCLC put notes in patient charts. A provider suggested the IBCLC send the provider a staff message in EPIC after seeing their patient. This has led to increased communication and collaboration. For a few months there was not enough space in the pediatric department for the IBCLC and she had to use a very small triage room to meet with clients. After a few months some space opened up. G. How readily would the pilot be scalable or replicable? Describe cautions and considerations when considering scaling, or replicating the Pilot. (i.e. Success dependent on personality/skills set, or activities appropriate under certain conditions like size, target population, etc.) Collaboration between WIC and a pediatric practice would certainly be replicable. All that is required is a laptop with the WIC software and a small storage space for supplies. Such a collaboration could be like this project with an IBCLC, but valuable collaborations could also be made with a WIC registered dietician or WIC nutrition educators. If space was available, it would be possible to house a whole WIC department in with a pediatric practice, which would be beneficial for clients because if appointments could be coordinated, it would reduce the number of trips out for appointments that families need to make. It would also increase collaboration between WIC staff and pediatric providers. Considerations for similar collaborations include needing to be flexible and innovative. When two organizations with very different computer systems and organizational structures are working together and trying to schedule clients together, it can be challenging to find ways to communicate and to schedule clients. It would likely be easier to start a collaboration small at first, with one staff member, like our project. Trying to have WIC and a pediatric practice collaborate on a large scale could be very beneficial, but would involve much more organization. H. Will the activities and their impact continue? If so, how? If not, why? We hope to be able to keep this position going by having the position begin billing insurance for lactation appointments 1/1/2019. One potential issue is that the clinic manager has said that once we begin billing for services, the clinic will begin charging us rent. The rent rate may be higher than the reimbursement for lactation appointments. We are working to resolve this.

5 Question 1 - Are breastfeeding rates in this clinic changing over time? Newborn Appointment An unusually large percentage of babies born in June 2017, May 2018, and June 2018 were exclusively breastfed at their newborn appointment (85%, 86.5%, and 87.5%, respectively). Rates for the other months range from 61% for babies born in March 2018 to 82% for babies born in November There is not a clear increase or decrease in breastfeeding rates for babies born between June 2017 and August BirthDate * FEED_NB Crosstabulation FEED_NB 2 Mixed 1 Breastfed Feeding 3 Formula Fed Total BirthDate JUN 2017 Count % within BirthDate 85.2% 3.7% 11.1% 100.0% JUL 2017 Count % within BirthDate 62.5% 28.1% 9.4% 100.0% AUG 2017 Count % within BirthDate 72.0% 16.0% 12.0% 100.0% SEP 2017 Count % within BirthDate 69.6% 17.4% 13.0% 100.0% OCT 2017 Count % within BirthDate 70.8% 12.5% 16.7% 100.0% NOV 2017 Count % within BirthDate 81.8% 9.1% 9.1% 100.0% DEC 2017 Count % within BirthDate 71.0% 12.9% 16.1% 100.0% JAN 2018 Count

6 % within BirthDate 73.3% 23.3% 3.3% 100.0% FEB 2018 Count % within BirthDate 68.6% 14.3% 17.1% 100.0% MAR 2018 Count % within BirthDate 60.7% 25.0% 14.3% 100.0% APR 2018 Count % within BirthDate 73.0% 18.9% 8.1% 100.0% MAY 2018 Count % within BirthDate 86.5% 13.5% 0.0% 100.0% JUN 2018 Count % within BirthDate 87.5% 4.2% 8.3% 100.0% JUL 2018 Count % within BirthDate 78.1% 18.8% 3.1% 100.0% AUG 2018 Count % within BirthDate 75.0% 16.7% 8.3% 100.0% Total Count % within BirthDate 74.1% 16.0% 9.9% 100.0%

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8 2-Month Appointment Babies born in January 2018 (67%), June 2018 (61%), May 2018 (59%), November 2017 (58%), October 2017 (54%), and June 2017 (52%) were slightly more likely to be breastfed at their 2-month appointment than babies born in August 2017 (48%), September 2017 (44%), or July 2017 (41%). As with the newborn appointment, there is not a clear increase or decrease in breastfeeding rates for babies born between June 2017 and July However, if June 2017 and March 2018 are disregarded, the general trend between July 2017 and July 2018 is an increase in the percentage of babies who are exclusively breastfed at their 2 month appointment, from 41% to 54%. BirthDate * FEED_2M Crosstabulation FEED_2M 2 Mixed 1 Breastfed Feeding 3 Formula Fed Total BirthDate JUN 2017 Count % within BirthDate 51.9% 14.8% 33.3% 100.0% JUL 2017 Count % within BirthDate 40.6% 12.5% 46.9% 100.0% AUG 2017 Count % within BirthDate 48.0% 16.0% 36.0% 100.0% SEP 2017 Count % within BirthDate 43.5% 30.4% 26.1% 100.0% OCT 2017 Count % within BirthDate 53.8% 23.1% 23.1% 100.0% NOV 2017 Count % within BirthDate 58.3% 8.3% 33.3% 100.0% DEC 2017 Count % within BirthDate 54.8% 3.2% 41.9% 100.0% JAN 2018 Count

9 % within BirthDate 66.7% 16.7% 16.7% 100.0% MAR 2018 Count % within BirthDate 46.4% 7.1% 46.4% 100.0% APR 2018 Count % within BirthDate 58.3% 22.2% 19.4% 100.0% MAY 2018 Count % within BirthDate 58.8% 26.5% 14.7% 100.0% JUN 2018 Count % within BirthDate 60.9% 4.3% 34.8% 100.0% JUL 2018 Count % within BirthDate 54.5% 18.2% 27.3% 100.0% Total Count % within BirthDate 52.4% 15.7% 31.9% 100.0%

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11 Does having seen a lactation consultant after hospital discharge increase the likelihood of breastfeeding? Newborn Appointment Babies who saw a lactation consultant after discharge were significantly more likely to be exclusively breastfed at their newborn appointment (80%; t(454) = 3.025, p =.003) than babies who did not see a lactation consultant (68%). The babies seen by Jessica (84%) and Lisa (83.5%) had the highest rates of breastfeeding. However, the samples sizes for Albany and the various combinations of lactation consultants were too small to interpret meaningfully. In addition, the category Other was used prior to 2018, whereas the lactation consultants included in Other were split out in 2018, which makes comparison of the Other category difficult to interpret in this data that combines 2017 and LactationConsultant * FEED_NB Crosstabulation FEED_NB 1 Breastfed 2 Mixed Feeding 3 Formula Fed Total LactationConsultant Albany Count % within LactationConsultant 66.7% 33.3% 0.0% 100.0% JB Count % within LactationConsultant 84.1% 14.3% 1.6% 100.0% JB and Albany Count % within LactationConsultant 100.0% 0.0% 0.0% 100.0% JB and Lisa Count % within LactationConsultant 66.7% 33.3% 0.0% 100.0% JB and Lisa and Alba Count % within LactationConsultant 100.0% 0.0% 0.0% 100.0% Lisa Count % within LactationConsultant 83.5% 15.4% 1.1% 100.0% Lisa and Albany Count

12 % within LactationConsultant 66.7% 33.3% 0.0% 100.0% No Count % within LactationConsultant 67.9% 12.9% 19.2% 100.0% Other Count % within LactationConsultant 74.5% 25.5% 0.0% 100.0% Total Count % within LactationConsultant 74.1% 16.0% 9.9% 100.0% 2-Month Appointment Babies who saw Jessica Barton (alone or in combination with other lactation consultants) after discharge were more likely to be exclusively breastfed at their 2-month appointment (66%; t(330) = 2.290, p =.023) than babies who did not see Jessica (49%). Similar to the newborn appointment results, the babies seen by Lisa (61%) and Jessica (72%) had the highest rates of breastfeeding. However, the samples sizes for Albany and the various combinations of lactation consultants were too small to interpret meaningfully, and the category Other changed over time, so its interpretation is unclear. LactationConsultant * FEED_2M Crosstabulation FEED_2M 1 Breastfed 2 Mixed Feeding 3 Formula Fed Total LactationConsultant Albany Count % within LactationConsultant 50.0% 0.0% 50.0% 100.0% JB Count % within LactationConsultant 71.7% 8.7% 19.6% 100.0% JB and Albany Count % within LactationConsultant 100.0% 0.0% 0.0% 100.0% JB and Lisa Count % within LactationConsultant 46.2% 7.7% 46.2% 100.0%

13 JB and Lisa and Alba Count % within LactationConsultant 0.0% 0.0% 100.0% 100.0% Lisa Count % within LactationConsultant 60.7% 16.4% 23.0% 100.0% Lisa and Albany Count % within LactationConsultant 100.0% 0.0% 0.0% 100.0% No Count % within LactationConsultant 48.1% 14.8% 37.0% 100.0% Other Count % within LactationConsultant 36.4% 29.5% 34.1% 100.0% Total Count % within LactationConsultant 52.4% 15.7% 31.9% 100.0% Logistic regression analyses examining the relationship between seeing Jessica Barton after discharge and exclusive breastfeeding showed that seeing Jessica Barton is a statistically significant predictor of exclusive breastfeeding at the 2-month appointment but not at the newborn appointment. How are the pediatricians doing? What are their breastfeeding rates for their patients? Newborn Appointment Babies who were seen by Dr. Kos (77.5%) and Dr. Ames (76%) were most likely to be exclusively breastfed at their newborn appointment than babies seen by Dr. Mic (69%).

14 Ped * FEED_NB Crosstabulation FEED_NB 2 Mixed 1 Breastfed Feeding 3 Formula Fed Total Ped Ames Count % within Ped 76.2% 16.1% 7.7% 100.0% Kos Count % within Ped 77.5% 12.5% 10.0% 100.0% Mic Count % within Ped 68.6% 19.6% 11.8% 100.0% Total Count % within Ped 74.1% 16.0% 9.9% 100.0%

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16 2-Month Appointment Babies who were seen by Dr. Kos were most likely to be exclusively breastfed at their 2-month appointment (64%), followed by babies seen by Dr. Ames (49%) and Dr. Mic (43.5%). Ped * FEED_2M Crosstabulation FEED_2M 2 Mixed 1 Breastfed Feeding 3 Formula Fed Total Ped Ames Count % within Ped 48.6% 15.9% 35.5% 100.0% Kos Count % within Ped 64.1% 11.1% 24.8% 100.0% Mic Count % within Ped 43.5% 20.4% 36.1% 100.0% Total Count % within Ped 52.4% 15.7% 31.9% 100.0%

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18 Is one of the pediatricians more likely to have their patients see a lactation consultant? Is one more likely to have them see me? Babies were equally likely to see Jessica Barton regardless of who their pediatrician is. Ped * JB_flag Crosstabulation JB_flag Total Ped Ames Count % within Ped 81.1% 18.9% 100.0% Kos Count % within Ped 82.5% 17.5% 100.0% Mic Count % within Ped 83.7% 16.3% 100.0% Total Count % within Ped 82.5% 17.5% 100.0% Babies are equally likely to see a lactation consultant regardless of who their pediatrician is. Ped * LC_visit Crosstabulation LC_visit Total Ped Ames Count % within Ped 47.6% 52.4% 100.0% Kos Count % within Ped 51.2% 48.8% 100.0% Mic Count

19 % within Ped 48.4% 51.6% 100.0% Total Count % within Ped 49.1% 50.9% 100.0% Anything else? Any other interesting questions? Lactation Consultation by Birth Month Babies born in November 2017 were most likely to see Jessica Barton after discharge (36%). Babies born in February 2018 were least likely to see Jessica Barton after discharge (6%), followed by August 2018 (8%) and July 2018 (9%). BirthDate * JB_flag Crosstabulation JB_flag Total BirthDate JUN 2017 Count % within BirthDate 81.5% 18.5% 100.0% JUL 2017 Count % within BirthDate 84.4% 15.6% 100.0% AUG 2017 Count % within BirthDate 88.0% 12.0% 100.0% SEP 2017 Count % within BirthDate 73.9% 26.1% 100.0%

20 OCT 2017 Count % within BirthDate 79.2% 20.8% 100.0% NOV 2017 Count % within BirthDate 63.6% 36.4% 100.0% DEC 2017 Count % within BirthDate 80.6% 19.4% 100.0% JAN 2018 Count % within BirthDate 83.3% 16.7% 100.0% FEB 2018 Count % within BirthDate 94.3% 5.7% 100.0% MAR 2018 Count % within BirthDate 75.0% 25.0% 100.0% APR 2018 Count % within BirthDate 78.4% 21.6% 100.0% MAY 2018 Count % within BirthDate 75.7% 24.3% 100.0% JUN 2018 Count % within BirthDate 87.5% 12.5% 100.0% JUL 2018 Count % within BirthDate 90.6% 9.4% 100.0% AUG 2018 Count % within BirthDate 91.7% 8.3% 100.0% Total Count % within BirthDate 82.5% 17.5% 100.0%

21 Babies born in June 2018 were most likely to be seen by a lactation consultant (67%), followed by March 2018 (64%) and November 2017 (64%). Babies born in February 2018 were least likely to be seen by a lactation consultant (37%), followed by September 2017 (39%), August 2017 (40%), and June 2017 (41%). BirthDate * LC_visit Crosstabulation LC_visit Total BirthDate JUN 2017 Count % within BirthDate 59.3% 40.7% 100.0% JUL 2017 Count % within BirthDate 46.9% 53.1% 100.0% AUG 2017 Count % within BirthDate 60.0% 40.0% 100.0% SEP 2017 Count % within BirthDate 60.9% 39.1% 100.0% OCT 2017 Count % within BirthDate 45.8% 54.2% 100.0% NOV 2017 Count % within BirthDate 36.4% 63.6% 100.0% DEC 2017 Count % within BirthDate 48.4% 51.6% 100.0% JAN 2018 Count % within BirthDate 56.7% 43.3% 100.0% FEB 2018 Count % within BirthDate 62.9% 37.1% 100.0% MAR 2018 Count

22 % within BirthDate 35.7% 64.3% 100.0% APR 2018 Count % within BirthDate 43.2% 56.8% 100.0% MAY 2018 Count % within BirthDate 51.4% 48.6% 100.0% JUN 2018 Count % within BirthDate 33.3% 66.7% 100.0% JUL 2018 Count % within BirthDate 37.5% 62.5% 100.0% AUG 2018 Count % within BirthDate 45.8% 54.2% 100.0% Total Count % within BirthDate 49.1% 50.9% 100.0% Pediatrician by Birth Month BirthDate * Ped Crosstabulation Ped Ames Kos Mic Total BirthDate JUN 2017 Count % within BirthDate 25.9% 51.9% 22.2% 100.0% JUL 2017 Count % within BirthDate 34.4% 31.3% 34.4% 100.0% AUG 2017 Count % within BirthDate 26.0% 44.0% 30.0% 100.0% SEP 2017 Count

23 % within BirthDate 13.0% 39.1% 47.8% 100.0% OCT 2017 Count % within BirthDate 33.3% 20.8% 45.8% 100.0% NOV 2017 Count % within BirthDate 27.3% 40.9% 31.8% 100.0% DEC 2017 Count % within BirthDate 32.3% 41.9% 25.8% 100.0% JAN 2018 Count % within BirthDate 20.0% 33.3% 46.7% 100.0% FEB 2018 Count % within BirthDate 22.9% 42.9% 34.3% 100.0% MAR 2018 Count % within BirthDate 25.0% 32.1% 42.9% 100.0% APR 2018 Count % within BirthDate 45.9% 32.4% 21.6% 100.0% MAY 2018 Count % within BirthDate 37.8% 21.6% 40.5% 100.0% JUN 2018 Count % within BirthDate 37.5% 33.3% 29.2% 100.0% JUL 2018 Count % within BirthDate 43.8% 28.1% 28.1% 100.0% AUG 2018 Count % within BirthDate 41.7% 29.2% 29.2% 100.0% Total Count % within BirthDate 31.4% 35.1% 33.6% 100.0%