SummaryThe Centering Healthcare Institute offers two group care models, one for pregnant woman (known as CenteringPregnancy) and one for new mothers and babies (known as CenteringParenting), that integrate health assessment, education, and support into a unified program. Groups meet in ten 2-hour sessions in which participants receive health assessments, learn care skills, participate in facilitated discussions, and develop a support network. A study of CenteringPregnancy found that group care participants received better prenatal care, had fewer preterm births, were more likely to initiate breastfeeding, and had better prenatal knowledge than those receiving "usual" care. Sites using the model also report an enhanced capacity to serve nonpregnant patients, as the group sessions free up resources previously used to provide one-on-one care.Strong: The evidence consists primarily of randomized controlled trials that test the impact of the CenteringPregnancy care model on key outcomes, including adequacy of prenatal care, likelihood of a preterm birth, and rates of sexually transmitted infections.
Developing OrganizationsCentering Healthcare Institute
Boston, MA and Washington, DC
Date First Implemented1998
The program was piloted in 1994 and formalized in 1998.
Age > Adult (19-44 years); Vulnerable Populations > Children; Gender > Female; Age > Fetus; Vulnerable Populations > Impoverished; Age > Infant (1-23 months); Vulnerable Populations > Medically or socially complex; Age > Newborn (0-1 month); Vulnerable Populations > Women
Problem AddressedInadequate prenatal care is common (especially among minorities) and associated with poor health outcomes, including preterm delivery and low birth weight. Providing adequate prenatal care in a one-on-one setting can be difficult for busy clinicians who face continued pressure to increase productivity. Because clinicians often provide the same kinds of education and pre- and postnatal care to women in similar stages of their pregnancy and/or parenting, group visits may offer the potential to provide better and more efficient care. However, such visits are often not available.
- Lack of prenatal care, especially among minority groups: In 2006, 5.7 percent of non-Hispanic black women who gave birth received inadequate prenatal care, followed closely by Hispanic women (5 percent). The comparable figure among non-Hispanic white women is 2.3 percent.1
- Leading to poor outcomes: Numerous studies have shown that inadequate prenatal care is associated with poorer pregnancy outcomes, particularly an increase in the risk of preterm delivery, low birth weight, and small-for-gestational-age infants.2 For example, one study found that women who received inadequate care had a 2.8 times greater risk of a preterm delivery.3
- Largely unrealized potential of group visits: Because education and care needs are quite similar among women in similar stages of pregnancy and/or parenting, the provision of pre- and postnatal care is well suited to group visits. In fact, physicians offering group visits for appropriate patients have increased their productivity by as much as 30 percent and reduced appointment wait times by about two-thirds,4 while simultaneously achieving high levels of patient satisfaction; studies show that 96 percent of women prefer receiving prenatal care in groups.5 Despite these potential benefits, group care remains uncommon, although interest and adoption is growing among agencies looking to enhance access and patient satisfaction and reduce costs.
Description of the Innovative ActivityThe two models include 9 to 10 2-hour sessions that focus on ongoing patient assessment, education, and support provided in a small group setting by a health care clinician (e.g., a physician, nurse practitioner, or midwife) trained in pre- and postnatal care. Key elements of the program are described below:
- Program logistics: The CenteringPregnancy model brings together groups of 8 to 12 pregnant women in a similar period in their pregnancy, while the CenteringParenting model brings together 5 to 7 mother-and-baby pairs. Participants represent a range of ages, educational attainment, socioeconomic levels, and ethnicities. The CenteringPregnancy model includes 10 2-hour prenatal care group sessions, beginning in the second trimester (12 to 16 weeks) and going through 40 weeks. Compared with traditional one-on-one care (which offers approximately 2 hours of prenatal care over the course of the entire pregnancy), CenteringPregnancy offers substantially more time with a provider (20 hours), thus enabling patients to examine issues in greater depth, enhance health behaviors and self-care skills, build social support, address sensitive topics, and reduce stress. Once women complete the CenteringPregnancy model, they can continue with the next phase of group care via the CenteringParenting model that provides well-woman/well-baby care. This program is also structured as 10 2-hour education/assessment sessions that begin postpartum and extend through the baby's first year of life.
- Key model elements: Both group-class models have 13 essential elements, as described below:
- Health assessment: One-on-one health assessments are provided within the group space; assessments occur on a mat placed in the corner of the meeting room. Basic privacy is maintained by the use of a low-to-the-ground assessment area, playing of music, and general activity associated with check-in and socializing that occurs at the snack table. Assessment activities that demand greater levels of privacy can be performed after the group session in an examination room.
- Structured session plans: Each session has an overall, structured plan of activities.
- Core content: The Centering Healthcare Institute has developed a framework to guide the content of the sessions. Although topic emphasis may vary, all essential content is covered over the course of the 10 sessions. Institute-developed materials are referenced at meetings and used for self-care. In addition to being available in English and Spanish, the materials have been translated into Arabic, Vietnamese, and Chukese (as of May 2009). Providers complete a tracking form at the end of each session to document the content provided.
- Circle format: The group is conducted in a circle to facilitate learning, social interaction, and problem sharing.
- Group composition: The composition of the group is stable but not rigid, which promotes supportive relationships while still allowing for new members.
- Group size: Between 8 and 12 patients participate in each group, a size considered optimal to promote the process.
- Self-care: Participants are empowered to embrace self-care activities. They take their own blood pressure and weight and record the results on their chart. They have access to chart data including results of laboratory and imaging tests. If program leaders recommend it, they also check their own urine with urine dipsticks. (This process is considered educational, despite the lack of evidence that urine dipstick use improves outcomes.) CenteringParenting participants weigh and measure their babies (including head circumference) and continue to monitor their own weight.
- Facilitative leadership: Group leaders adopt a facilitative leadership style, which enables participants to contribute to the discussion and problem-solving (as opposed to a didactic leadership style, which involves one-way communication of information).
- Consistent leadership: Leaders tend to stay with their groups throughout all sessions, thus providing continuity of care from a single provider. The clinician and co-facilitator stay with the group throughout the 10 sessions, thus providing important continuity of care to the women.
- Culture of respect: Group conduct honors the contribution of each member. The group facilitators try hard to listen to each woman as she shares her own cultural beliefs and values. Occasionally, a talking stick is passed among participants.
- Outside support: Group members have the opportunity to involve family members or partners in pre- and postnatal care if they so desire.
- Social interaction: Sessions include opportunities for socializing within the group, so that participants can build a community that provides support.
- Outcomes evaluation: Ongoing evaluation of outcomes ensures that patients receive high-quality care.
- Insurance reimbursement: Insurers reimburse providers as they would for an individual encounter with a provider; a chart note is made at every visit for documentation purposes.
References/Related ArticlesCentering Healthcare Institute Web site. Available at: http://www.centeringhealthcare.org
Baldwin K. Comparison of selected outcomes of CenteringPregnancy versus traditional prenatal care. J Midwifery Womens Health. 2006;51(4):266-72. [PubMed]
Carlson NS, Lowe N. CenteringPregnancy: a new approach in prenatal care. MCN Am J Matern Child Nurs. 2006;31(4):218-23. [PubMed]
Grady MA, Bloom K. Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health. 2004;49(5):412-20. [PubMed]
Ickovics J, Kershaw T, Westdahl C, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol. 2007;110(2 Pt 1):330-9. [PubMed]
Contact the InnovatorSharon Schindler Rising, CNM, MSN, FACNM
President and CEO
Centering Healthcare Institute
8737 Colesville Road, Suite#307
Silver Spring, MD 20910
89 South Street #404
Boston, MA 02111
Jeannette R. Ickovics, PhD
School of Public Health
60 College Street, Room 432
New Haven, CT 06520
Innovator DisclosuresDr. Ickovics and Ms. Rising have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsA randomized controlled trial (RCT) of the CenteringPregnancy model found that group care participants received better prenatal care, had fewer preterm births, were more likely to initiate breastfeeding, and had better prenatal knowledge than those receiving usual care. Another RCT found that the program reduced sexually transmitted infections, which are associated with increased risk of preterm delivery. Sites using the model also report an enhanced capacity to serve nonpregnant patients and to meet payer documentation requirements.
Strong: The evidence consists primarily of randomized controlled trials that test the impact of the CenteringPregnancy care model on key outcomes, including adequacy of prenatal care, likelihood of a preterm birth, and rates of sexually transmitted infections.
- Better pregnancy outcomes: An RCT found that CenteringPregnancy participants were less likely than those enrolled in usual care to receive inadequate prenatal care (26.6 percent of program participants received inadequate care, compared with 33 percent of those getting usual care) or to deliver prematurely (9.8 vs. 13.8 percent). Participants were also more likely to initiate breastfeeding (66.5 vs. 54.6 percent) and had better prenatal knowledge, greater readiness for labor and delivery, and higher satisfaction with their prenatal care.
- Fewer sexually transmitted infections among African-American teens: Another RCT found lower rates of chlamydia and gonorrhea among teenage African-American CenteringPregnancy participants than among those receiving usual care (8.9 vs. 22.8 percent); in addition, those with no history of sexually transmitted infections who were assigned to CenteringPregnancy were more likely to remain infection free up to 1 year postpartum (4.6 vs 10.8 percent).
- Enhanced access for other patients and services: Some participating sites have found that CenteringPregnancy frees up capacity and space to serve nonpregnant patients, thus reducing waiting times for appointments or enhancing the ability to accept new patients. Essentially, by removing prenatal care patients from one-on-one care, sites add clinical capacity that can be used for other billable activities.
- Enhanced documentation: Participating sites report an enhanced ability to meet payer documentation requirements related to various components of prenatal care and education.
Context of the InnovationThe Centering model was developed by Sharon Schindler Rising, a Connecticut nurse-midwife, after she found herself facing an overwhelming demand for prenatal care and realized that much of this care was duplicative across patients. The model was piloted in 13 groups (3 of which were teen groups) in 1993 and 1994; positive quantitative and qualitative outcomes prompted the development of a formal 2-day training workshop and broader dissemination of the program in 1998. As of March 2013, the models are active in more than 125 approved Centering sites in almost every state. International work is happening in Canada, the United Kingdom, Australia, Netherlands, and Germany. Sites include hospitals, public health clinics, women's and family health centers, private physician offices, birthing centers, and other organizations. The model has also been implemented at several military bases and Indian Health Service sites. New group care programs, including programs focused on diabetes and senior care, are currently in development.
Planning and Development ProcessSites that implement the CenteringPregnancy model have typically followed these key steps:
- Gathering basic information: The site gathers initial information about the model from a variety of sources, including Centering Healthcare Institute's information packet, attendance at an implementation seminar, completion of the Readiness Assessment on the institute's Web site (http://www.centeringhealthcare.org/), and published articles.
- Contracting with Centering Healthcare Institute for a Model Implementation Plan: An institute consultant is assigned to the site to provide guidance to the formation of a steering committee to oversee the planning process. The committee might include an administrator, provider, nurse, medical assistant, front desk clerk, social worker, consumer, or representative from a relevant community agency.
- Redesigning the system: The consultant provides an overview of the Centering model to all staff at the site and then spends the rest of the day working with the Steering Committee on issues of redesign.
- Creating an implementation timeline: The planning committee creates a timeline for implementation and submits it to the institute, which provides appropriate support and consultation.
- Training: An initial 2-day training session is conducted when the site has completed the redesign work. The session focuses on helping the clinicians and co-facilitators learn how to facilitate groups. In the second year of the implementation, there may be a 1-day workshop for further work on facilitation skills.
- Applying for site approval: The site applies for formal approval from the institute, which applies specific standards during the approval process. Site approval involves (1) completing a self-evaluation report; (2) documenting that the 13 essential elements are in place; and (3) undergoing a 1.5-day site visit, during which the visitor meets with key organizers, reviews documents, observes a group meeting, and provides technical assistance as needed. After the visit, the site receives a formal written report that provides feedback and approval designation. Sites are required to keep active membership and submit yearly data updates to the institute's Centering Counts data system.
- Planning for sustainability: The site should plan for sustainability. For example, the site creates a budget that includes ongoing expenses for patient materials, staffing, food, administrative time, and data collection and evaluation. The site also has a plan to have at least 60 percent of eligible patients receive care through Centering.
- Requesting consultation as needed: The site may request consultation from Centering Healthcare Institute at any time. The institute encourages sites to stay in touch with the organization and to be part of the larger network of CenteringPregnancy sites.
Resources Used and Skills Needed
- Staffing: Sites may use existing staff or hire new staff for the program. Staffing for the models typically include a clinician (e.g., a physician, nurse practitioner, or midwife) who is credentialed to provide prenatal care, along with a nurse or medical assistant. Sites may also have a part-time program coordinator (who devotes perhaps 1 day per week), social worker, translator, or administrative staff to handle patient check-in.
- Costs: Costs are highly variable across sites; therefore, general estimates cannot be provided. Centering Healthcare Institute can offer cost estimates depending on individual site characteristics, usually by providing cost data from similar sites that have implemented the program. Some general cost guidelines appear below:
- Initial costs: The site will review all costs with Centering Healthcare Institute during the contracting phase.
- Ongoing costs: Ongoing costs consist primarily of staffing-related expenses, along with patient materials, food, administrative time, and data collection/evaluation. Sites should budget materials cost of $20 per participant.
- Physical space: The program can be implemented wherever prenatal care occurs, such as in community health centers, physician office waiting rooms (during evening hours), birthing centers, hospital clinics, public health clinics, and other locations. The meeting room must be large enough to comfortably provide care, including space to accommodate approximately 20 participants sitting in an open circle (i.e., with no central barrier such as a conference room table), a mat on the floor in the corner of the room (for assessments), a check-in table for measuring blood pressure and weight, and a table for refreshments.
Funding SourcesCentering Healthcare Institute
The March of Dimes through its state chapter grants has provided considerable funding to sites for startup and continuing costs. Funding also has come from insurers and private foundations. Recently, the Strong Start initiative from the Center for Medicare & Medicaid Innovation has funded several Centering sites as part of evaluating enhanced prenatal care.
The Centering Healthcare Institute has benefited from small grants from the national office of the March of Dimes and has been the recipient of substantial funding from Strategic Grant Partners, a Boston-based family foundation.
Tools and Other ResourcesThe Centering Healthcare Institute has developed a table titled 10 Rules for Redesign that is based on the six Institute of Medicine aims; it is available in Rising SS, Kennedy HP, Klima C. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health. 2004;49(5):398-404. [PubMed]
Other tools available from CenteringPregnancy include Mom's Notebook; Facilitator's Guide to the Mom's Notebook; Family Notebook; Group Facilitation Monograph; and many other tools to help facilitate group sessions. Visit http://www.centeringhealthcare.org for more information on these materials.
Getting Started with This Innovation
- Ensure that group facilitator is a good listener: A good listener can help participants share ideas and concerns, participate in problem-solving, and become engaged in their own care.
- Obtain adequate training: Group facilitation is a special skill that is not necessarily intuitive.
- Have a champion at the site: The champion can be an administrator, physician, midwife, or other individual who believes that the model offers better service to patients.
- Develop evaluation plan and budget: Set up a system to evaluate the program's impact, and add the program to the site's budget as a distinct line item.
Sustaining This Innovation
- Fully embrace the new care model: Consider transitioning the model to the point that it becomes the primary (or only) option for receiving pre- and postnatal care. Centering Healthcare Institute recommends that a site start with three or four pilot groups but then expand the program quickly so that it serves at least 60 percent of eligible patients, thus making it the primary model of care for patients. Patients should be allowed to opt out of group care if they so desire.
Additional Considerations and Lessons
Use By Other Organizations
Several OB/GYN and family medicine residencies have incorporated Centering group leadership into resident rotations, as have several midwifery schools. In addition, other models of group care, focused mainly on chronic care, are being used in some sites; these are often called "shared medical appointments."
Schramm WF. Weighing costs and benefits of adequate prenatal care for 12,023 births in Missouri's Medicaid program, 1988. Public Health Rep. 1992;107(6):647-52. [PubMed]
Krueger PM, Scholl TO. Adequacy of prenatal care and pregnancy outcome. J Am Osteopath Assoc. 2000;100(8):485-92. [PubMed]
5 Centering Healthcare Institute. The Centering Model for Group Health Care. Cheshire, CT: Centering Healthcare Institute.
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Service Delivery Innovation Profile
Original publication: May 26, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 26, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.