Meeting the Health Care Needs of Underserved Women

Meeting the Health Care Needs of Underserved Women

Event Date: 
Thursday, May 19, 2011

AHRQ's Health Care Innovations Exchange held a Web Seminar on Meeting the Health Care Needs of Underserved Women on May 19, 2011.

Participants

Host: Judi Consalvo, Program Analyst, Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality
 
 
Moderators:
Beth Collins Sharp, PhD, RN
Senior Adviser for Women's Health at AHRQ  
 
Sharon Schindler Rising, MSN, CNM, FACNM
President and CEO of the Centering Healthcare Institute Inc.

Additional Information

Panel Slides
 

Slide 1

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Meeting the Health Care Needs of Underserved Women

Web Seminar
May 19, 2011

http://www.innovations.ahrq.gov

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Slide 2

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How to Access Closed Captioning

Closed Captioning:

  • Click on the link, “Closed Captioning,” on the top right hand corner of the participant console.
  • A new window opens displaying the captioning.

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Slide 3

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What Is the Health Care Innovations Exchange?

  • Publicly accessible, searchable database of health service delivery innovative strategies and tools
  • Successes and attempts
  • Innovators' stories and lessons learned
  • Expert commentaries
  • Learning and networking opportunities
  • New content posted to the Web site every two weeks

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Slide 4

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Innovations Exchange Web Event Series

How to find archived materials
Go to the Events & Podcasts tab on our site: http://www.innovations.ahrq.gov. A transcript of this event along with the slides will be available in a week.

Next Events
Web events in June and July—look for the announcements

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Slide 5

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Innovations Exchange Web Event Series (cont.)

CNE Credit

Continuing nursing education (CNE) credit is available for this Web event. You must attend the entire event and complete the evaluation to receive one credit.

After the event, you will receive detailed information in an e-mail from programevaluations@ncqa.org on how to complete the evaluation and claim your CNE credit.

Evaluation

Please complete the evaluation even if you do not wish to receive credit. Thank you—we appreciate the feedback.

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Slide 6

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Housekeeping

  • No phone is necessary for this event.
  • You may just stream the audio over the Web through the speakers on your computer.
  • For help, notify the Vcall team through the question window at the bottom of the screen.
  • To refresh your screen, hit f5.

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Slide 7

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Submitting Questions

  • When: Any time during the presentation
  • How: Send a written question through the question window

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Slide 8

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Web Seminar Objectives

At the completion of this Web seminar, you will be able to:

  • Describe disparities in health care for women in underserved populations
  • Describe health care challenges for women in underserved populations
  • Explain the Centering Model approach to prenatal health care for women in underserved populations
  • Identify evidence-based methods for providing prenatal health care for women in underserved populations.

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Slide 9

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Web Seminar Agenda

Beth Collins Sharp (AHRQ):

  • Describe disparities in health care for women in underserved populations
  • Describe health care challenges for women in underserved populations

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Slide 10

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Web Seminar Agenda (cont.)

Sharon Schindler Rising (Centering Healthcare Institute):

  • Explain the Centering Model approach to prenatal health care for women in underserved populations
  • Identify evidence-based methods for providing prenatal health care to women in underserved populations.

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Slide 11

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Today's Event Moderator

Beth Collins Sharp, PhD RN
Sr. Advisor, Women's Health
U.S. Agency for Healthcare Research and Quality (AHRQ)

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Slide 12

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The Health of Underserved Women in Context

2010 National Healthcare Quality Report and National Healthcare Disparities Report:

  • Health care quality and access are suboptimal, especially for minorities and poor people.
  • Quality is improving; access and disparities are not.

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Slide 13

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The Health of Underserved Women in Context (Cont.)

Overall, some services, areas, and populations merit urgent attention, including:

  • Cancer screening and management of diabetes.
  • States in the central part of the country.
  • Residents of inner-city and rural areas.
  • Disparities in preventive services and access to care.

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Slide 14

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The Health of Underserved Women in Context (Cont.)

Health Care Delivery and Systems

  • Females were more likely to have a usual primary care provider than males (79.9% compared with 72.6%).
  • In all years, females were more likely than males to be unable to get or delayed in getting needed medical care, dental care, or prescription medicines.

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Slide 15

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The Health of Underserved Women in Context (Cont.)

Health Care Quality and Disparities in Women

  • Extracts and summarizes data related to women
  • From 2004 to 2007, rates of 3rd and 4th degree lacerations decreased from 40 to 32 per 1000 vaginal deliveries.

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Slide 16

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Healthcare Cost & Utilization Project (HCUP) 2008 Data: Reasons for Hospital Stays


Reason
Male Female
Pregnancy and Childbirth
n/a
4.7
Circulatory System
3.1
2.8
Perinatal (Newborns)
2.3
2.1
Respiratory System
1.8
2.1
Digestive System
1.5
1.9
All Other Conditions
7.8
9.6

 

 

 

 

 

 

 

 

 

 

 

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Slide 17

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HCUP Report: Hospitalizations Related to Childbirth

1997 to 2008:

  • Use of forceps to aid delivery declined by 32%, from 14% to 10%.
  • 40% of all childbirth stays were billed to Medicaid, 53% to private insurers, 4% were uninsured, and the rest were other payers.
  • Roughly 36% of all childbirth hospital stays in 2008 occurred in the South compared to 16% in the Northeast. The West and Midwest accounted for 26% and 23%, respectively.

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Slide 18

Screenshot of HealthCare.gov

Affordable Care Act

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Slide 19

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The Centering Model for Providing Prenatal Care to Underserved Women

Sharon Schindler Rising, MSN, CNM, FACNM
President and CEO of the Centering
Healthcare Institute, Inc.

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Slide 20

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What is the Centering Healthcare Institute?

  • Founded in 2001 as a non-profit
  • Uses the evidence-based model of group care called Centering, which promotes major health care quality goals
  • Established areas of Centering include CenteringPregnancy and CenteringParenting
  • CenteringDiabetes is being piloted

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Slide 21

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Centering Model and Underserved Women

  • Centering Care is appropriate for all women
  • Majority of Centering sites are in public clinics, FQHC's, hospital clinics
  • Contact information for the submitter.
  • Centering Care has particular benefits for underserved women:
    • Culturally appropriate care, often in language-specific groups
    • Individual health empowerment
    • Community building

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Slide 22

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Imagine…

  • No waiting
  • Time to really listen to your patients
  • Time for sharing and learning
  • Saying things only once
  • Better health outcomes
  • Having fun

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Slide 23

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Quotes:

  • “This is the one thing in my week that brings me joy” - provider
  • “We came at the same time and left at the same time and something happened the whole time we were there” - participant
  • “This is the ‘bestest' way I know of to receive care!” - participant

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Slide 24

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CenteringPregnancy: Design

Initial intake to system as usual

  • History
  • Physical
  • Lab work

Group of 8-12 women with similar due dates

Groups start between 12-16 weeks and meet for 10 sessions throughout pregnancy

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Slide 25

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CenteringPregnancy Visit Schedule

Four sessions every 4 weeks - 16, 20, 24, 28 weeks

Six sessions every 2 weeks - 30, 32, 34, 36, 38, 40 weeks

Postpartum reunion - Between 1-2 months postpartum

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Slide 26

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Components of Centering Care

Assessment

Education

Support

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Slide 27

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Assessment

  • Individual health care exam with provider conducted in group space
  • Patients directly involved in collecting and recording their own health data
  • Provider/patient contact time increased 10 fold
  • Care reimbursed in the usual way

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Slide 28

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Education

  • Participants have time to talk in depth about important information and questions
  • General session plan guides discussion
  • Opportunity to explore cultural beliefs and values enhances appropriateness of content
  • Group provides efficient way to share information

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Slide 29

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Support

Groups provide:

  • A vehicle for social change
  • An opportunity to learn from each other
  • Fun and interesting sharing
  • Centering builds communities one group at a time

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Slide 30

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Centering Essential Elements

13 Essential Elements
define the Centering model of care, including CenteringPregnancy

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Slide 31

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1. Health assessment occurs within the group space

Assessment area in the group space:

  • Care is normalized
  • Privacy is protected

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Slide 32

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2. Participants are involved in self-care activites

Self-Assessment activities:

  • Weight
  • Blood pressure
  • Lab tests
  • Other specific assessments for particular health conditions
  • Self-Assessment Sheets

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Slide 33

Text Description Follows

3. A facilitative leadership style is used

Group

  • Interactive
  • Inquiry and dialog
  • Shared experiences
  • Patient centered

Class

  • Didactic
  • Passive
  • Structured
  • Provider centered

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Slide 34

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4. Each session has an overall plan
5. Attention given to overall content

Personal Goals, Exercise, Stress management, Infant development, Nutrition, Childbirth preparation

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Slide 35

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5. Attention is given to general content outline (emphasis may vary)

We talk about what the group wants to talk about.

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Slide 36

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6. There is stability of group leadership

  • Build trust
  • Group history
  • Continuity of care
  • A provider and co-facilitator guide the group through all sessions

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Slide 37

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7. Group conduct honors the contribution of each member

Group Ground Rules:

  • Confidentiality
  • Personally comfortable sharing
  • Appropriate language translation
  • Culture of respect prevails

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Slide 38

The group is conducted in a circle

8. The group is conducted in a circle

Picture provided

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Slide 39

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9. Opportunity for socializing is provided
10. The composition of the group is stable but not rigid

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Slide 40

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11. Group size is optimal to promote the process

Too Few:

  • Productivity issues
  • Awkward
  • Difficult for shy individuals
  • Pressure to participate
  • Didactic

Too Many:

  • Limited dialogue; didactic
  • Assessments challenging
  • Individuals lost in the crowd
  • Community building more challenging

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Slide 41

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12. Involvement of family support persons is optional

  • One support person
  • The same one each time
  • No children

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Slide 42

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13. There is ongoing evaluation of outcomes

Benchmarking topics

  • Patient experience
  • Attendance at visits
  • Health outcomes: preterm birth, method of delivery, breastfeeding

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Slide 43

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Measuring the Impact of Centering Care

  • Impact of CenteringPregnancy most thoroughly studied
  • Results particularly pertinent for underserved women:
    • Higher rates of preterm births
    • May have cultural/language challenges
    • Increased number of social risk factors

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Slide 44

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Effects of Group Prenatal Care on Outcomes

Results from a Two-Site Matched Cohort Study

Centering groups vs. traditional care: N=458

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Slide 45

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Impact of Model Effect on Outcomes

Premature infants of group patients were significantly larger than those in individual care (2397.8 versus 1989.9 grams)

Group patients maintained their premature pregnancies two weeks longer than individual care patients (34.8 weeks versus 32.6 weeks)

Moving a pregnancy along one additional week from 34 to 35 weeks gestation results in a 42 percent decrease in hospital costs

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Slide 46

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Effects of Group Prenatal Care: Randomized Controlled Trial

National Institute of Mental Health
No. MH 611, 2001 through 2006; Ickovics et al., Obstetrics and Gynecology 110, 2 (August 2007): 3230–9

Study Sample (N=1,047)

Pregnant women 14 to 25 years, HIV negative
English/Spanish, public clinics in New Haven, CT and
Atlanta, GA

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Slide 47

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STUDY SAMPLE, SELECT CHARACTERISTICS

 
GROUP
(n=653)
INDIV
(n=394)
AGE, years (range 14-25)
20.3
20.6
EDUCATION, years (26% drop out)
11.4
11.3
GA STUDY ENTRY, weeks
18.0
18.4
NULLIPAROUS
62%
61%
SMOKE, current
21%
20%
Hx STI
52%
50%
African American
81%
74%
Latina
11%
17%
Hx PRETERM BIRTH
4.0%
7.1%
PRENATAL DISTRESS, mean
15.2
13.7

 

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Slide 48

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Research Outcomes: 2006 Randomized Controlled Trial

Chart showing per 1000 women in group, 40 preterm deliveries averted; 60 per 1000 for African American women

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Slide 49

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PRENATAL CARE ATTENDANCE, SATISFACTION & COST

  • 78% average attendance
  • Less than adequate care (Kotelchuck): 26% vs 33%, OR =0.68 (.50-.91)
  • Women in group care had greater satisfaction with care, (F=27.2, p<.001)
  • Significantly higher prenatal knowledge and readiness for labor & delivery (each p<.001)
  • Higher readiness for baby care (p=.0560)
  • No difference antenatal or in delivery costs (p>0.69)

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Slide 50

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“This is the one thing in my week that brings me joy” - provider

“We came at the same time and left at the same time and something happened the whole time we were there” - participant

“This is the ‘bestest' way I know of to receive care!” - participant

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Slide 51

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Centering Healthcare Institute

info@centeringhealthcare.org
www.centeringhealthcare.org

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Slide 52

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Contact Us!

Please send comments and suggestions to:
info@innovations.ahrq.gov

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Transcript

Judi Consalvo
Thank you. Good afternoon, everyone. On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to our Web event entitled: Meeting the Health Care Needs of Underserved Women. I'm a Program Analyst in the AHRQ Center for Outcomes and Evidence. We are very excited today about our topic and glad to see that you share our enthusiasm. We will be polling you in a few minutes to get a better feel for who has joined us today. We are pleased to offer closed captioning on this Web seminar. To access the closed captioning, please click on the link called closed captioning. That is on the top right hand of your screen view. After you click the link, a new window will display the captioning.

Some of you may be new to the AHRQ Health Care Innovations Exchange so I would like to take a minute to give you an overview before I introduce today's moderator. The aim of the Health Care Innovations Exchange is to increase awareness, implementation and uptake of innovation strategies and health care delivery in order to improve health care quality and reduce disparity. To meet this goal, we provide a one-stop shop Web site that offers free access to searchable descriptions of innovations and quality tools, learning networks, and educational resources. The collection includes evidence-based quality improvement innovations as well as improvement initiatives that did not succeed, providing users with valuable lessons learned from these attempts. Health care professionals can learn about the process of innovation and implementation through articles, perspectives, and adoption guides. Interactive learning events include Web seminars, discussion forums, online chats, and in-person meetings. We post new content to the Web site every two weeks on a range of topics.

The AHRQ Innovations Exchange regularly sponsors Web events to support you in developing and adopting innovations in health care delivery. We invite you to take a look at archived materials from our most recent Web events on new ways to communicate with patients. It can be found on our Web site at www.innovations.ahrq.gov. And we hope you will join us for future events that will be announced on the Healthcare Innovations Exchange Web site. Stay tuned for new Web events in June and July.

We also welcome your thoughts on other topics we could address with you. At the end of today's event, you will be asked to complete a brief evaluation form. Your comments will help us to plan future events that meet your needs. You can also e-mail your comments and ideas to us at info@innovations.ahrq.gov.

We are pleased to offer continuing nursing education credit for this Web event. If you wish to receive the credit, you will receive an e-mail within a few days that will contain detailed information on how to complete the Web event evaluation and claim your credit. The e-mail will come from program evaluations@NCQA.org with the subject line NCQA evaluation and credit claim. For those who do not wish to receive credit, we would also appreciate it if you would complete the evaluation as well, which will be included in this e-mail. We carefully review this feedback and use it to improve our learning events.

While we don't anticipate any technical problems, I would like to give you a few tips in case you experience any. First no phone is necessary for this event. You may just stream the audio over the Web through the speakers on your computer. If you experience any difficulties with the sound coming through your computer speakers, please notify the VCall attendant via the questions window. If you have any trouble with the slides or your connection to the Web event, try pressing F5 to refresh your screen. We are recording this event so that anyone who could not make it today or needs to leave the Web seminar early can listen to the recording or read the transcript. You will be able to find links to a downloadable recording, the slides, and a transcript on the AHRQ Health Care Innovations Exchange Web site in a few days. In fact, if you would like to download the slides for today's presentation you can find them through the link at the top of this screen.

You may submit questions at any time through the questions window as pictured in the screenshot. We will be answering questions near the end of the Web event, time permitting.

As you can see, we have identified a number of objectives for this Web seminar. This seminar will help you to describe health care disparities and health care challenges for underserved women, explain the Centering Model approach to prenatal care for underserved women, and identify evidence-based methods for providing prenatal care for underserved women.

Before we get started, I would like to give our faculty a sense of our audience today. Shortly you will see a poll pop up, and we would like for you to answer the polling questions that you will see appear on screen.

Okay, would you describe yourself as a physician, a nurse, other clinician, a researcher, a health administrator and a policymaker. Please take the time to fill this in quickly. Okay. We have the results really quickly. So I see the majority of the folks on today's call are nurses. And next – well there is a tie between health administrator and researchers. And then other clinician and policymakers. So great, this gives our faculty and all of you an idea of who is participating in this Web event today.

So let's turn to our agenda for today. Our moderator, Dr. Beth Collins Sharp, will give us an overview of health care disparity and health care challenges for underserved women. Beth is the Senior Adviser for Women's Health at AHRQ. Our innovator, Sharon Schindler Rising, will then explain the Centering Model approach to prenatal care for underserved women. She will also identify evidence-based methods for providing prenatal care to underserved women. Sharon is the President and CEO of the Centering Healthcare Institute Inc. Okay, so let's start with Beth.

Beth Collins Sharp
Good afternoon or morning, depending on your time zone. It is a pleasure to be here today for this Web seminar discussion about meeting the health care needs of underserved women. I would like to start with some information from AHRQ's reports on national health care quality and disparity.

For the eighth year in a row, the Agency for Health Care Research and Quality has produced two reports. These reports measure trends and effectiveness in the areas of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. The 2010 report includes data through 2008 and added chapters on care coordination and health system infrastructure. The reports present in chart format the latest available findings on quality of–and access to–health care. The National Health Care Quality Report tracks the health care system through quality measures and the Disparities Report summarizes health care quality and access among various racial, ethnic, and income groups and other priority populations such as residents of rural areas, people with disabilities, and women. Overall, according to the 2010 reports, across all Americans, health care quality and access are sub-optimal especially for minorities and poor people. This is not new news. However, quality is improving but access to that care is not improving, and disparities among priority populations continue.

If we narrow our focus a bit, some service areas and populations merit urgent attention in the areas of cancer screening and management of diabetes. Also, meriting attention are states in the central part of the country, residents of inner-city and rural areas, and those with disparities in preventive services and access to care.

Drilling down now to women, we find that in the next slide that in 2008 women were more likely to have a usual primary care provider compared to men. However, women were more likely to be unable to get health care or they were delayed in getting the health care that they need.

In the next slide, we will see a report. As you may know, women's health is a priority population for AHRQ, meaning women have unique health care needs or issues that require special focus. The Agency for Health Care Research and Quality supports research in all aspects of health care provided to women. This fact sheet that you see in this slide focuses on findings in the Qualities and Disparities reports, which were integrated throughout both reports. A document on this slide extracts and summarizes the measures and data about women in a single document. So, as you can see, one example of a women's health finding is that the rates for third and fourth degree lacerations decrease significantly. Declines were found in all urban and rural locations, but in the most recent years there were lower rates of obstetric trauma for residents of small metropolitan and micro-politician and rural areas compared to women living in suburban areas. Declines were also seen among all racial and ethnic groups. In all years, blacks and Hispanics had lower rates of obstetric traumas than whites, and in all years Asians-Pacific Islanders had higher rates than whites. If we look at an achievable benchmark for reducing obstetrical trauma, it could be obtained by most racial ethnic groups in about three years. Whites would need about four years while Asian-Pacific Islander women would need more than 23 years.

I invite you to take a look at the one page on this slide for this document, and feel free to share the document as it is in the public domain.

Another recent and interesting report from AHRQ comes from the HCUP Program. HCUP stands for the Health Care Cost & Utilization Project. The report here focuses on reasons for hospital stays. Conditions related to pregnancy, childbirth, and live born infants were the most frequent reasons for hospitalizations, accounting for nearly one in four discharges or 23% in 2008. Stays with principal diagnosis of previous C-section nearly doubled, up 96% between 1997 and 2008. I think I will say that one again. Stays with the principal diagnosis of previous C-section nearly doubled between 1997 and 2008. Stays – hospital stays with the principal diagnosis of high blood pressure during pregnancy – increased by 22% during this period. By the way, the annual number of childbirth stays in hospitals had been increasing by an average of 2% a year starting in 1999. But, between 2007 and 2008, the number of hospital stays for childbirth fell by 300,000 from 4.5 to 4.2 million. This is an interesting development to keep an eye on in the future. Finally, 33% of childbirths were by cesarean section, and that is up from 21% in 1997. In fact, C-sections were overall the most commonly performed operation – operating room procedure in US hospitals. Again, I feel a need to say that again. C-sections were overall the most commonly performed operating room procedure in US hospitals. And next slide.

HCUP also produced a report on hospitalizations related to childbirth. A few facts to highlight from this report are about trends over time. So from 1997 to 2008, the use of forceps to aid delivery declined by 32%. 40% of all childbirth stays were billed in Medicaid and 53% to private insurers, 4% were uninsured, and the rest were other payers. And roughly 36% of all childbirth hospital stays in 2008 occurred in the South compared to 16% in the Northeast. Interestingly the West and the Midwest accounted for 26 and 23% respectively in the middle.

And then finally, on the last slide, you will see that I would like to mention the Affordable Care Act. An important context for women's health care is found in the ACA, also known as health-care reform. You may go to healthcare.gov and search on women and find very helpful information that is on the page pictured in this slide. For example, new health plans must now cover certain preventative services without cost-sharing. But more importantly, there is critical information about coverage for individuals with pre-existing conditions. Denial of coverage for children with pre-existing conditions is no longer allowed. That provision is already in place. This will expand to adults in 2014 so that a woman with a pre-existing pregnancy or a disability can no longer be denied coverage or be charged more. Now that is great, but many people are concerned that 2014 is still far away for those who can't get health insurance right now because of a pre-existing condition. However, there is a special program within the ACA legislation to help individuals during this transition time through 2014, and it appears that it is not well known. I just learned about it myself last week, so that's why it is not on this slide. The letters for you to remember are PCIP: pre-existing condition insurance plan. PCIP. You can search for it on healthcare.gov but they have also recently, very recently, added a separate address at www.PCIP.gov. Go there and you will find some unique opportunities to get health insurance coverage prior to 2014. There is a requirement that to be eligible you cannot have been able to find insurance coverage for six months period, but the program could be tremendously beneficial as a stopgap between that six-month period and 2014. So I encourage you to investigate that.

And with that, I hope you have a sense of the landscape and context for the issues of implementation of innovations for health care of underserved women. You are welcome to contact me with further questions either directly or at our new Web address: AHRQwomenshealth@ahrq.gov. And with that, I will turn it over to Sharon.

Sharon Schindler Rising
Thank you, Beth. I am really pleased to be here with you today and to talk with you about a model of care that has been developed and that is being promoted by the Centering Health Care Institute. This institute is a non-profit, which was founded in 2001. And the next slide will show you more about it. This is an evidence-based group care model, which is called Centering and which promotes major health quality goals. The established areas of Centering include CenteringPregnancy and CenteringParenting, which involved well-woman, well-baby care through the first year of life and beyond, and also CenteringDiabetes, which is now in its early stages of piloting. We have found is that this is a model that really does work for any health population. And so there is interest throughout the lifecycle in how to use Centering as a very strong evidence-based model of group care.

Well, on the next slide, we talk a little bit about why Centering is especially appropriate for underserved women. We have been working with sites for over 15 years now and we have found that over 85% of all of our 300 plus sites around the country are in federally qualified health centers, public health clinics, hospital clinics, and there are additional models that are active in the private sector as well. We also are doing a considerable amount of work with some of the Indian tribes around the country. So we have a real focus on underserved women and find that Centering is particularly appropriate for women who are new immigrants, who now can come and receive care in groups that are language specific and with people who can help them to navigate the whole health care system. Many women have said it was wonderful to get care in a group with other people who speak my language and with other women who come from the same cultural background that I have. So, we see here, culturally appropriate care in language-specific groups allows women to have an opportunity to really talk about the care, and what's happening to their body, and also have access to their charts and chart data. This increasing sense of personal empowerment; and really it develops throughout the course of pregnancy, and often is very obvious when women come in for birth. There is also this lovely community building that happens within the group as women get to know each other better and find that they actually perhaps even live down the street from each other.

There are three components of Centering Care as the next slide shows. There is assessment and there is education and there is support. And I have felt that all care really should have these three components. So I would like to have you imagine for a moment what it might be like to be in a situation, get care in an area where there is no waiting where there is no waiting to get in for your care visit. Now my experience with sites around the country is that there are very few places that don't have a problem with waiting, with crowded waiting rooms, with waiting for charts, and for a room to be available. So we all wait. And now there is even an opportunity to really say things only once, to have time to listen to patients, and really have enough time for sharing and learning. And moreover to have fun. I think that we are having less and less fun these days as the challenges for providing health care are really increasing with more numbers, with increased emphasis on productivity, and sites are really being challenged to provide the amount of time that is needed, to provide the kind of care that all of us are wanting to provide.

So the next slide then also talks about some of the comments that we have gotten from people. So if you could imagine a provider saying to you, as one did one day when she called me, this is the one thing in my week that brings me joy. Or another physician said about his colleague, “when he leaves that Centering room he looks as if he is 6 inches off the floor, and he has a huge smile on his face.” So imagine that sort of feeling. Or also having the group participant saying we came at the same time and left at the same time and something happened the whole time we were there. Now I can remember women saying, “why did she get called before I did, I have been here longer.” I don't know if you've had that experience. But here is a measured amount of time, the group starts on time and ends on time, which also means that the clinic schedule can be planned around that, and you can actually plan your time, and women coming to the group can plan their time. They can plan their child care; they can plan their work schedules. It is very lovely to know when you are going to be able to leave.

And then recently, as one woman said, this is the “bestest” way I know of to receive care. And that's the kind of the evaluations that we are getting from around the country, that women strongly prefer getting their care this way. Think about having 10 times more time than you currently have with your provider, or as a provider having 10 times more time than with the patients that you are caring for than you would have in individual care.

So the next slide please. So I would like to go over the initial intake to the system. So women coming into care have had their initial intake so there has been a history that has been taken, they've had their physical exam, they've had their lab work done. And now they are invited to join with a group of 8-12 women who have similar gestational age to receive all the rest of their care. The group starts between 12-16 weeks and meets through 10 sessions, really following the ACOG schedule so already you can think of how well you are going to know these women by the time your pregnancy ends. Next please.

So four sessions every four weeks and 16, 20, 24, 28 weeks or, if the group gets registered a little later for care, perhaps you have a lot of women who register sometimes between 18 and 20 weeks, then you might fast-forward the schedule a bit. But every four weeks and every two weeks, and then there is a postpartum visit that would be mainly to talk about one's birth experience. Women like to see each other's baby, so it is a fun time to come together, but we know that women need many opportunities to tell their birth stories or they will relive their experience during their next pregnancy, perhaps in a way that is not quite as healthy. We also have CenteringParenting that would then start where CenteringPregnancy leaves off, so there would be a seamless transition to parenting, and CenteringParenting is well-woman, well-baby care. So it provides a lovely system for well-woman care, a system we don't currently have in this country.

If a woman develops complications during this time, she would need to make extra visits to handle the complications. In some sites, depending on who the provider is, it might be that the extra individual visits aren't even needed and the provider can take care of whatever the problem is within the group. However, often the woman has to go elsewhere for some extra assessment and oversight. And she would be given the option then of staying with the group and making additional visits or simply transferring out of care. We know that most women–if they possibly can–elect to stay with the group. The group has just become too important, and then they go elsewhere, often with an maternal fetal medicine specialist for the assessment and treatment of whatever the condition is.

Next please. So let's think then that all care should have–besides the checkup or the assessment–an opportunity for what we call education or what I often call the ability of women to test out their own wisdom with others in the group; and then an opportunity to have community building; and think about what we usually can do in our traditional care. We know it is very difficult for us actually to address all three of these areas. So let's look a little more closely at the components. The next slide please.

So the assessment itself is actually the checkup, and it happens within the group's base. This is a model that does not use exam rooms at all unless there is some particular problem that has arisen. So now you have to again do a little imagining. So imagine this space that has privacy to it, but that is warm and inviting so music is playing, the women come directly to that room, they don't stop at the check-in desk, they don't sit in the waiting room at all. They come directly to the room, they have materials that they record on or, if there is a paper chart, they record directly on their charts. They take their own blood pressure and weight, and then they have this individual assessment with their provider off in a corner of the room; and we say this is about a three minute assessment because women's questions – one woman's question is another woman's question–so the questions really come to the group. So the provider–instead of repeating again and again and again why this probably is ligament pain or perhaps what the essence of genetics counseling might be–the provider brings that to the group, and as a group they talk about this. Since this is care, it is reimbursed in the usual way. So, however, it is whether it is global or individual billing, there is really no change in that because, again, every woman has had an individual assessment with her provider.

So the education piece of it on the next slide talks about the ability then with this amount of time for participants really to talk in depth about things that are important to them. There is a plan that guides all of this discussion, but it is an opportunity for the provider to really sit back and listen and to further understand cultural beliefs and values, which are really what drive our behavior. I think that it is extremely hard for us to totally understand, to really understand the cultural beliefs and values of women who come from different cultures. We are still–no matter how hard we try–products of our own culture, and while women may be very respectful and listen to us as we come up with strategies, often the strategies that we come up with are really outside of their cultural beliefs, and they won't be implemented. So since we have a lot more to learn, there is not a lot of evidence for most of what we do. It's really wonderful to sit and listen, and that's what happens during this hour plus time where we sit together in our open circle and talk. And then this provides a really efficient way for us to share information. So again–not repeating ourselves again and again and again–but having one time to talk with a group and say how does this seem to you.

The next component is the support component, or community building as we might call it. And I think again groups provide this vehicle for social change, so as women think together about the community and about the needs for the community, it might not be unusual for women to sign a petition and get activated to really improve the care for their families within their community. Women learn from each other and have so much fun. It's fun and interesting sharing that goes on, and we often say Centering builds communities one group at the time. As one woman said on an evaluation, I really gained an appreciation of the difficulty of other women's lives. Again, we are fairly isolated and this is an opportunity for us to share cross culturally.

So as you see on the next slide–it starts with 13 essential elements that really define the Centering model of care. And as we have seen these elements can be translated to any health population. Today we are really focusing particularly on pregnancy and how these bear out in this model. So the first, the first element, and we talked about it just a little bit, is the health assessment that occurs within the group's space. And so why is that? Well, there is nothing particularly private about how a woman's belly grows. And as you know, women think they are either too big or too small or they are never just right. As they look around the group and they talk together, they see that they really are many sizes even though they are all at the same gestation, but this is done in a way that privacy is protected, so in the corner there is not an exam table that is used. So a little massage table or perhaps one of those thermal rest mattresses might be on the floor. I think that you can get a little feel for one assessment place there on the left that has some green plants, and that is kind of a separate area from the rest of the room and is using a massage table. So music playing, a little food in the corner, women chatting with each other, getting to know each other. And it is during this time that I would sometimes gauge the success of the group by how noisy it is. We want women to be talking to each other and sharing with each other, and what we find is that women start missing each other. So health assessment occurs within the group space, and it is a cornerstone piece of the model.

The second element is that participants are involved in self-care activities, and you see here a woman who is taking her blood pressure. Another woman who is looking through her charts, and behind there is another woman who is on the scale determining her weight. So these are self-assessment activities that happen. Women do their weight graphs, they take their own blood pressure, they chart it, and their progress record–if it is a paper chart–it is easy for them to put it right into their chart. If not, there might be a shadow chart that they would write on, and then all of this data is then taken over to the provider when they have their mass assessment. It's also a time when women complete self-assessment sheets that will then help to spring the discussions. So again, very active, and now all of this, the medical terminology, is getting demystified. They are reading their ultrasound reports, they are looking at their lab data, and this is really the activity that helps women to totally start owning their pregnancy.

The third one of the elements–also a really crucial one–is the facilitative style that is used. So Centering is never called a class. It is group. And if you think about the images that come to your mind when you think of group or class, I think you all – you might get the same images that are in front of you here. A group is interactive, and it is open to a sharing of experiences. It is really driven by the interest and the needs of the people in the group versus class that is really driven by us–by the teacher or the provider. Those of us who do breastfeeding classes or childbirth classes can relate to how a class might be structured somewhat differently, with objectives for the session and going down that content to make sure that it is all covered. It is more centered on what we think women should be learning in a particular time rather then what women are really interested in talking about and might be generating in terms of their questions. So in order to have this really work well in our training we really talk about interactive activities that are fun, that help to spring the discussion, and the self-assessment sheet is also used to spring discussion. It is always an open circle and having the appropriate space for Centering can be a bit of a challenge because we often have space that is a conference room with a table and other things that have to be moved, and that can be really, really difficult. But here we have an open circle, women see each other, and as we sit back as the facilitators for the group, we try really hard not to answer questions, but let the group answer the question, and then of course that helps us to get wiser as well, and then we throw in our thoughts and perhaps some evidence that we have that will help the discussion.

So the fourth element, each session has an overall plan, is really structured within the mom's notebook that is available, and so there are some guides, and there's a facilitator guide that helps the facilitators as they lead the group. It is important to have some content, but since there is a lot of material in the mom's notebook, that does relieve some of our sort of stress on we need to cover everything because we know that women have that to read at home and will share with their family.

And, as shown in the next slide, attention is given to general content outline, but we really talk about what is important to the group, so this is again our letting go of control. There is no reason, for example, for us to follow an outline that says we talk about stop smoking today if nobody in the group is smoking. And we may well need to talk about some event that has happened in the community. A shooting on the corner, something else that is happening that is really troubling the women, before we can get down to other issues that we might really want to be talking about.

In the next slide is the stability of group leadership, and so we talk about two people really owning the group, so this is a pairing of the provider and a co-facilitator in order – and so you really own the group for 10 sessions, and groups will trust in history, and this is the way to provide continuity of care. Many studies have shown that women–when asked whether or not they would want to know everybody who has provided care for them or who could possibly be with them for delivery or to have one provider throughout the pregnancy consistently–say they would prefer to have one provider. So, and this is lovely for us as facilitators for the group, because we really get to know the group.

So, next the group conduct honors the contribution of each person. It is really important; there are ground rules of course for confidentiality. We need typical guidelines for this. But women share things, share sensitive material that they have never shared with individual providers, and we have story after story of how this has happened, particularly in the area of domestic violence, but also perhaps depression and other things that happen with the family. There is support in the group to do that. So there is just a culture of respect that – and on the AHRQ Innovation's Web site, they have actually renamed this to say a culture of respect occurs within the group.

The next one shows how the group is conducted in a circle. We already talked about it, but you see here a picture of a circle – an open circle with women and you can imagine how much interaction might happen there. So importantly, there are many chairs, but there are not any tables. And then going on, there is opportunity for socializing and we know that it's important to have food, something that we socialize over and so there are healthy snacks - healthy is hardly the definer of snack, but having some kind of food there is important, whether it's fruit or granola bars or certainly water, and all the women then just gather around the table often and socialize that way. The group composition is stable, but women can be added to the group, and often by the third session we sort of think of the group as having formed, but it is important to have a full group, and the next slide really talks about the size of the group, which is important. So we think that having somewhere between eight and 12, maybe 10 women in the group, is about the right size for a group. So you know that too few is awkward, and maybe there is too much pressure on you to contribute and it is easy for us to get a bit didactic, but you cannot have too many there are assessments. All these women have their checkups, and we want everyone to have an opportunity to share. So somewhere around 10 and for productivity also–that is about the right number for most sites.

And then we talk a little bit about the involvement of family support people, and that is optional. Some groups have male partners involved, many of them have grandmothers and sisters that come, but it needs to be the same support person; and again confidentiality rules apply, and this is not a model that is child friendly. Remembering that, by the age of two, most children cannot be counted on for confidentiality. So again, the number of people in the group may be determined by the size of the group space as well.

And then the last element, which I will go over really quickly, is that there needs to be ongoing evaluation of outcomes. We always want to know if care has gotten better, so basic benchmarking and benchmarking topics will vary depending on what is really important to a particular site. But often we want to know how the patient experienced this and ve certain what their attendance is, and then we like to have some idea about outcomes.

The next slide, the impact of Centering Care, CenteringPregnancy is the most thoroughly studied and we've found the studies were primarily with underserved women, so we have been looking at particularly at preterm birth outcomes and somehow this fits with the cultural issues too that they might have.

The next slide just has a very quick overview of our first cohort study that was published in 2003 in Obstetrics and Gynecology looking at Centering groups from Yale and from Emory. These are public clinics, and the study looked at matched pairs – matched by age, race, parity and closest day of delivery. And in that particular study what we found was that–as the next slide shows–that if you were in a Centering group and you delivered preterm, you stayed pregnant two weeks longer and had a baby 1 pound heavier than your matched pair. So also we have found one of the health plans has said that moving a pregnancy along for one additional week, even from 34 to 35 weeks gestation, results in a 42% decrease in hospital cost. So we are particularly interested in the effect on preterm birth because it's one of our major societal costs.

The next slide has the overview of the randomized control trial. Both of these studies were led by Dr. Jeanette Ickovics, a primary investigator from the School of Public Health at Yale. The study sample has over 1,000 women, 14-25 years, from these same setting as the previous matched cohort. So here we see on the next slide it shows that the studies of demographics. Again both of these groups – group and individual–were essentially the same except that there were more African-American women who by chance were in group, and they had a lower history of preterm birth; and they measured higher on prenatal distress at the beginning of their pregnancies so these three things were accounted for in all the subsequent analysis.

So one of the major outcomes that the graph on the next slide shows us is that there was a 33% reduction in preterm birth for women who were in Centering groups and with the women, the African-American women, that was about 80% of the sample, there was a 41% reduction in preterm birth. One Medical Director said to me so for everyone in a half to 2 groups–you will save your system one preterm birth and that is really huge.

This data has been – is continuing to be replicated in several well constructed evaluation studies, and we have another randomized trial that is nearing completion and we will have those results in another few months in some very well-constructed evaluation studies around the country, so we continue to be really encouraged by this particular outcome.

The next slide has a few other outcomes from that study, and one is that the attendance is better in Centering; and we see attendance actually as being much better for that return postpartum visit, which is such an important visit. Women in Centering have had more adequate care and were brought better knowledge and readiness for baby care and they – women really love this model. The satisfaction of women who received care this way is very, very high. Again, this is replicated in all of our evaluations. We want all of our sites to do an evaluation of the model, and when women are asked about their experience with the model, they are highly satisfied; and we have done some – we have some data on women who have received care in the same site for previous pregnancies and then received care through Centering, and again women consistently say that Centering Care is at least as good, but most say it is better than the care that they got individually. So it is – it is very highly satisfying to the participants and also to the providers as well. Remember this quote, “the one thing in my week that brings me joy.” And 'how do I keep up my energy for individual care' is another thing that we often hear. We also hear that this has been culturally transformative. At agencies that – as one person said to me – one physician said that – that our staff has been so energized by this, and some now want to go back to school and become nurses, and so that the staff feels more empowered by this as well.

This is the – very brief overview of a model that is working extremely well with our vulnerable populations, with our new immigrants. We have materials that are translated into Spanish, and we also have materials in Arabic and Vietnamese and Creole that are coming, and so it is a model that just allows us to provide a level and quality of care for this population that I think is increasingly difficult for us to do in individual care.

So thank you.

Beth Collins Sharp
Thank you Sharon. This is Beth. We have received several questions. There are two here that I think are generally interesting to a number of folks. Actually three questions, but two on the same topic. I am going to give you both questions at the same time so that you might want to respond to both back and forth. One question, the one that we received two times was how this sort of open and group setting works with HIPAA considerations. And then the second one is related to health literacy considerations, when women are reading their lab and ultrasound results.

Sharon Schindler Rising
Okay, so the HIPAA question is one that, of course, we are concerned about and what the answer to that is that women always have a choice in terms of how they get their care and that they can certainly stay in individual care if they want to, but they have a choice in whether they are going to come to the group. They also are never, never asked or requested to share anything that they don't want to say. So women decide what they are willing to share in the group and, of course, confidentiality and confidentiality guidelines are reviewed – are reviewed continually and rules, ground rules are posted on the wall and again reviewed because we are always worried about breaches of confidentiality. Also, any chart material is there, just there for the woman so there is not any open access to a woman's chart. In terms of – in terms of sort of the literacy, the literacy issue is that – is that much of the activity that is done in group can be done with stories or with – and through games and does not necessarily demand the written facility of the woman. But in terms of lab tests, which is what the particular question was–lab tests and ultrasound reports: that those then would be gone over if a woman is unable to read or understand. It is important to review lab reports in a way that the woman gains increased understanding of the results. The report can be reviewed individually because there is another facilitator there who is working and available to the women. And often particular things are talked about in the group so what does it mean when there is a lab value of this or this? What does that mean to us? And – or what does it mean in the group? We might talk about it if you have a positive lab result like chlamydia. Where does that come from and let's talk about it generally so women start getting an idea of what this really means. What we have found with women in our Spanish groups is that they very quickly have been able to record their blood pressure and their weight even on the chart, so it does not take a lot for women to sort of make that transfer.

Beth Collins Sharp
Great, thank you. One – an additional question that we have had is about the economics of this sort of model. Specifically related to analysis of return on investment or a cost savings that you might – so do you have information about that – that data that you might be able to share with us?

Sharon Schindler Rising
We are in the process of really gathering cost data. As you know, it is a very complicated area as to whether you look at cost efficiency or cost effectiveness, and we are looking at this in a variety of ways and we do have some studies. The randomized control trial indicated that it seems as if this was maybe cost neutral. It is an investment and it – there is an investment and not so much in equipment, but certainly an investment in training. There is an investment in the space and needing to do some renovation even to have appropriate space to do groups in. We – with the data that we have, sort of the larger term societal investment we are looking at–the outcomes for preterm birth and increased breast-feeding rates and the reduction of sexually transmitted infections, and also documenting sort of a longer inter-conceptual period. There has been an estimate that we are saving around $2,000 per woman who is in Centering, and then multiply that by the number of women so a societal savings. Maybe even last year, that might approach the $40 million area. So there is a larger societal gain that is happening, but then there is the return on investment for a particular site, and so then that needs to be looked at in terms of access, in terms of marketing and growth. If you're wanting to actually grow, this is a model that is very attractive and that women tell other women about and a decrease in all of these missed appointments and the empty exam rooms, efficiency and effectiveness. It's a very complicated question, but we think that it will be a return on investment perhaps not immediately, but in the future. We are working with Medicaid, and we are seeing in some states that there is some enhanced reimbursement for Medicaid because, of course, they are very interested in the reduction in preterm births and the savings that are there.

Beth Collins Sharp
Wonderful, thank you. And we have about two minutes for one last question, and that is what do you do in the case of abnormal results or a patient has a problem and needs an individual assessment. How do you work in that individual assessment into this group activity?

Sharon Schindler Rising
Well it can – that can be done in a variety of ways. Usually we try to save a little time at the end of group if somebody needs to have a quick individual visit. If there is a problem, ideally we have found that out before the group, and have been able to reach the woman and perhaps she has already come in. Let's say there's a problem with her ultrasound or - and, if not, the woman is just asked to stay after or to make another appointment depending on the complication that might be involved.

Judi Consalvo
Thank you, Sharon. And thank you, Beth. This has been a very informative session and we appreciate both of you taking the time to be with us today. I am afraid we are now out of time and have to bring this Web event to a close. Please remember within a few days you will receive detailed information on how to complete the Web event evaluation and claim your CNE credit. Please complete the evaluation even if you will not be claiming credit. And as always, you can also contact us at any time at info@innovations.ahrq.gov.

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