Title V Transformation Tools
Recommendations to Support NPM 3 – Perinatal Regionalization
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Significance. The Title V Maternal and Child Health Services Block Grant to States Program guidance1 defines the significance of this NPM as follows:
Very low birth weight infants (‹1,500 grams or 3.25 pounds) are the most fragile newborns. Although they represented less than 2% of all births in 2010, VLBW infants accounted for 53% of all infant deaths, with a risk of death over 100 times higher than that of normal birth weight infants (>=2,500 grams or 5.5 pounds). VLBW infants are significantly more likely to survive and thrive when born in a facility with a level-III Neonatal Intensive Care Unit (NICU), a subspecialty facility equipped to handle high-risk neonates. In 2012, the AAP provided updated guidelines on the definitions of neonatal levels of care to include Level I (basic care), Level II (specialty care), and Levels III and IV (subspecialty intensive care) based on the availability of 62 appropriate personnel, physical space, equipment, and organization. Given overwhelming evidence of improved outcomes, the AAP recommends that VLBW and/or very preterm infants (‹32 weeks' gestation) be born in only level III or IV facilities. This measure is endorsed by the National Quality Forum (#0477).
Background. The Maternal and Child Health Bureau (MCHB) Title V Maternal and Child Health Services Block Grants to States Program has established 15 National Performance Measures (NPMs) for the 2015-2017 grant cycle. In order to effectively address the NPMs, MCH professionals need to think about not only the evidence and strategies to make change, but also the capacity of the workforce to carry out these activities. These lists identify online learning materials, resources, and evidence-based strategies and programs to support the knowledge sets and skills needed to advance each NPM.
Introduction. Six skill sets have been identified by the National MCH Workforce Development Center to support implementation of this NPM: (1) population health; (2) strategic planning and program design; (3) strategic alliances and effective partnerships; (4) consumer engagement and cultural and linguistic brokering; (5) policy and program implementation; and (6) communication.
In addition, two knowledge areas specific to the NPM topic area have been highlighted that are keyed to the evidence base and promising practices: (1) perinatal services background and (2)hospital NICU background.
The MCH Navigator, in collaboration with the Center, has developed this crosswalk to guide MCH professionals to online learning opportunities and implementation resources to support these skill sets.
Please click on the Read More buttons below for additional information, learning materials, and implementation resources. You can also email us with suggestions for additions.
Six skill sets have been identified to support implementation of this NPM:
1. Population Health
A renewed focus on MCH population health is key to achieving the NPMs in the era of health transformation. These skills enable Title V professionals to analyze how program interventions and their related health outcomes are distributed among a state’s MCH population. Population health skills complement all of Title V’s work, including program design and implementation, strategic partnerships and communication.
- Ability to calculate quality-adjusted life years (QUALYs) to quantify:
- Impact of appropriate level of care for very low birth weight infants
- Rates of morbidity/mortality by social, demographic and economic indicators
- Ability to develop estimates of death rates and implications based on percent of very low birth weight infants born in a hospital with a Level III+ neonatal intensive care units (NICU)
- Ability to conduct economic analyses for babies born in appropriate (or inappropriate) facilities, including transport costs and potential morbidities associated with inappropriate levels of care
- Ability to collect and review perinatal regionalization policies from all hospitals in state/territory
- Skills to obtain and establish coordinated data reports for key stakeholders
2. Strategic Planning & Program Design
Effective strategic planning and program design require the ability to base programs on defined goals and desired outcomes. Strategic planning should include a monitoring and evaluation system to track and monitor progress and inform program alterations as needed. Program design skills must ultimately be coupled with implementation, where program design is carried out.
- Skills to develop evaluation measures for targeted outreach and progress for the care of very low birth weight infants
- Skills in quality improvement to provide public health support of providers and health systems to make data-informed decisions
3. Strategic Alliances & Effective Partnerships
The wide array of stakeholders and partners in the field of MCH, from providers and insurers to women and children, require a set of skills in strategically aligning Title V goals with those of their partners. In the Title V world, there is an increasing interest in engaging unlikely or nontraditional partners to achieve the NPMs. The skills in this category take that into account and include unique partner groups linked to this measure.
- Ability to foster collaboration between public and private health care providers in perinatal regionalization efforts
- Skills to engage with Level I and Level II hospitals to review very low birth weight data
- Ability to align perinatal regionalization activities with low-risk cesarean delivery initiatives
- Ability to convene a multi-stakeholder group to assess effectiveness of current perinatal regionalization plans with partners from:
- Public Health
- State legislature
- Family advocacy groups
- Medicaid and other payers
- Hospital associations
- Managed care groups
- State/territory hospital regulators
- Health professional organizations
- Health plans
4. Consumer Engagement/Cultural & Linguistic Brokering
Consumers are arguably the most important stakeholders in MCH work, thus skills in consumer engagement and cultural and linguistic brokering are essential to moving the needle for each NPM. In some cases, consumer engagement includes negotiating with other stakeholders on behalf of MCH populations. Closely linked with this skills category are skills in communication and strategic alliances.
- Ability to engage women at risk and mothers of very low birth weight infants as peer educators
- Ability to navigate sensitivities around very low birth weight outcomes with women
5. Policy & Program Implementation
These skills ensure that MCH priorities are integrated into all aspects of policy and program implementation, as well as ensuring that policies and programs selected are well-aligned with NPMs and other MCH program goals. Implementing policies and programs with fidelity also requires skills in the implementation science drivers: technical and adaptive leadership; selection; training; coaching; systems intervention; facilitative administration; and decision support data systems.
- Skills to analyze and align NICU levels of care and maternal levels of care
- Skills to create or enhance voluntary reporting systems among Levels II and III care facilities
- Ability to support implementation of CDC/CoIIN Level of Care Assessment Tool (LOCATe)
- Ability to advocate for increasing numbers of Level III+ hospitals in rural areas to address disparities
- Ability to support hospitals or hospital associations with implementation science tools to ensure effective level adjustment when necessary
- Skills to analyze authorizing contexts related to levels of care in individual hospitals and determine with policy makers if there are opportunities for improvement
- Ability to determine legal authority behind existing memoranda of understanding regarding NICU levels of care regarding relevant agencies
- Skills to develop memoranda of understanding with Medicaid and other payers to develop policies that address appropriate Level III+ NICU care for very low birth weight infants
- Ability to analyze transport policies and procedures of Level II care facilities to appropriate Level III care facilities
- Ability to define policies, procedures, and incentives to women who deliver high-risk newborns in appropriate facilities (beyond transport of infants)
Communication skills support the creation and delivery of effective messages between MCH professionals, professional and community partners, and populations served by Title V. Effective communication ensures the delivery of appropriate messages to audiences in the way that they were intended and is key to all aspects of MCH work. These skills are linked closely with skills in strategic partnerships and cultural and linguistic brokering.
- Ability to effectively reach women of childbearing age with culturally appropriate and compelling level of care messages
- Ability to create unified messages for parents and clinicians about delivery of risk-appropriate hospital levels and their impact on morbidity/mortality outcomes of very low birth weight infants
In addition to skills, each NPM requires a knowledge base that will help Title V progress effectively in the measure. Knowledge should be considered at the foundation of achieving all measures.
1. Perinatal Services Background
- Knowledge of definition of high-risk vs. low-risk pregnancies and appropriate levels of care for each
- Knowledge about financial, geographic and cultural barriers for women to deliver in appropriate level centers, including access to primary care and obstetric services that allow for early identification of high-risk pregnancy
- Knowledge of morbidity-related outcomes for very low birth weight infants
- Knowledge of morbidity and mortality rates by level of NICU services
- Knowledge of available data sources, e.g., pregnancy risk assessment monitoring system (PRAMS) and birth
2. Hospital NICU Background
- Knowledge of hospital assigned risk-appropriate levels that ensure high-risk infants are born in facilities with appropriate technology and specialized providers
- Knowledge of authorizing body that sets levels of care and how specific levels of care are determined
- Knowledge about geographic distribution of levels of care of hospitals in the state/region and awareness of distribution’s alignment with need
- Knowledge of basic hospital funding sources and levels of reimbursement for care at specialized locations, as well as financial impact of changing NICU levels
- Knowledge of provider/hospital system processes when a high-risk pregnancy is identified
See other online learning resources related to health transformation, collected in the Health Transformation Learning Laboratory.
1 Health Resources and Services Administration. 2014. Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, Appendix F, p. 76.