Nebraska Perinatal Quality Improvement Collaborative and Nebraska Medicine
The Nebraska Perinatal Quality Improvement Collaborative (NPQIC) works with hospitals across the state with the mission to improve the quality of care for mothers and newborns. The NPQIC implements models of care within larger hospital systems, serving maternal and pediatric populations affected by prenatal substance use and other health conditions. Nebraska Medicine is a large inner city academic center that includes an obstetric clinic with obstetricians and midwives, 2 academic family practice groups, and private practice physician groups that are delivering in the Nebraska Medicine setting.
The program works with pregnant patients with opioid use disorder (OUD), offering them clinical prenatal care, and then transitions them to receive in-hospital delivery care and subsequent postnatal care. After delivery, both the birth parent and neonate, are evaluated, monitored, and receive necessary treatment.
Individualized Patient Centered Care
A plan of safe care (POSC) with detailed health goals is critical for pregnant people in recovery. For each birth parent identified with prenatal substance exposure, the NPQIC creates an individual and customized POSC. The mother’s plan is stated at the time of admission in the hospital, and later is couplet with the plan for the newborn. The POSC provides details related to continuity of care, starting in the prenatal clinic, from the referring obstetrician and/or the primary care provider (PCP), to other adult care providers for services, such as mental and behavioral health, addiction and recovery care, substance use disorder (SUD) medication treatment providers, and social services.
The POSC is maintained in the electronic medical record (EMR) system; it flows through the maternal hospitalization during delivery and is again reviewed and updated based on the medical needs and family’s health goals at the time of discharge. When the newborn is discharged with the birth parent, a corresponding POSC for the parent-infant dyad is prepared. If the newborn remains in the hospital after the mother is discharged, the newborn’s plan is updated with all the necessary information to facilitate continued communication and engagement of the parent. This plan of care is used during the entire hospitalization, whether the neonate is receiving pharmacological therapy for neonatal opioid withdrawal syndrome (NOWS) or is just being monitored for NOWS symptoms.
Physicians, nurses, discharge coordinators, and social workers all collaborate when developing the plan, building a therapeutic alliance with the family during the implementation. When the plan is finalized, both the custodial parent/caregiver and discharging provider sign the document. The newborn’s POSC is signed by the birthing parent, and, if the dyad is separated, the plan is signed by the legal guardian. Both POSCs are distributed to all discharge care teams to facilitate the family’s care continuation outside of the hospital.
Program staff spend significant time in crafting each individual POSC. The success of a POSC depends on clear communication starting early between clinicians, labor and delivery staff, and appropriate documentation of the family health history in the EMR. This continuous communication allows hospital staff to inform the neonatal providers of impending delivery and includes appropriate anticipatory guidance information for the birth parents and caregivers.
Communications Strategies
A basic tenet of the NPQIC guidance is to regard a family’s health history and prenatal substance use as a reason to provide the best possible support for parents in recovery and their newborns. NPQIC encourages hospital staff to use medically accurate, respectful terminology and language that is relationship-based, non-judgmental, and non-stigmatizing to garner important medical information from families with a history of substance use. All pregnant people in recovery deserve a clinical structure in place that meets their needs: from those with chronic conditions requiring pain management therapy to those with SUDs, and those who may or may not be in recovery at the time of delivery. Open conversations based on mutual respect can solidify trust and are a cornerstone of the therapeutic alliance. Staff are profoundly impressed with parents’ abilities to be forthcoming with sensitive health information to ensure the newborn’s health and well-being.
Anticipatory Guidance
The team begins offering anticipatory guidance about managing the health of a newborn with NOWS, early on during the prenatal clinics. The mother’s POSC contains significant anticipatory and in-the-moment guidance with clarity about what to expect during delivery and perinatal care. Depending on the duration of substance use during pregnancy, the NPQIC developed protocols with recommendations for implementation of non-pharmacological care Eat, Sleep, Console (ESC) for neonates exposed to opioids in-utero. The goal is to manage successfully the NOWS symptoms before hospital discharge, avoid medical risks associated with acute opioid withdrawal, and have a successful transition from hospital to home.
Care Coordination and Clinic-based Processes
All staff in the neonatal intensive care unit (NICU), and those in the labor and delivery unit received training on the comfort and care of neonates and maximizes nonpharmacologic methods while increasing parental and family involvement in the treatment and care of the newborn.
At all times the team’s priority is the safety and well-being of a newborn and reducing hospital and/or NICU re-admission for NOWS treatment and management. After delivery, there is frequent communication with the parent/caregiver to assess NOWS symptoms. NPQIC’s protocol is a 5-day observation period leading to treatment as indicated. If the birth parent’s health history is not available, the delivery team monitors closely the newborn to assess severity of NOWS symptoms. As needed, the clinical team at Nebraska Medicine utilizes pharmacological treatment in combination with non-pharmacologic care to manage NOWS symptoms. Treatment length can be extensive, depending on the severity of the withdrawal symptoms.
An addiction medicine physician, who is also a pediatrician, is consulted to help care for the family with perinatal opioid exposure. The addiction medicine physician is an essential resource for the family to provide specialty trained support and additional information necessary in the POSC. Just as important, the addiction medicine physician assesses the birth parents to ensure they receive appropriate, evidence-based treatment, and will continue to have medical care and mental health services after discharge.
Staff support birth parents in being proactive in handling NOWS symptoms. The NPQIC encourage breastfeeding to manage a newborn’s withdrawal symptoms unless the birth parent confirmed using other substances during pregnancy. The hospital has a strong lactation support team, including a NICU lactation consultant who works with families of newborns who experience poor feeding, cluster feeding and excessive sucking.
The NPQIC strongly advocates for screening for maternal depression, as a component of quality obstetric care and a best practice recommended by the AAP Bright Futures in caring for newborns and their families. Consequently, Nebraska Medicine has cultivated very engaged perinatal mental health services within the medical unit. In addition to screening for substance use, all birth parents are screened for anxiety and depression. Protocols are in place to work with pregnant and parenting people who have anxiety, depression, or suicidal thoughts.
All newborns born with exposure to opioids and other substances in-utero are referred to a neurodevelopmental follow-up team that is supported by the State of Nebraska. All newborns qualify for evaluation and neurodevelopmental follow-up to assess if they are achieving developmental milestones and receive further specialty assessment if developmental delays are diagnosed.
The Therapeutic Alliance
Building a therapeutic alliance is a major goal that increases the mother, newborn, and family’s positive health outcomes. Birth parents can be with their newborn in the hospital from 5 days in the nursery, to 40 days in the NICU. Staff celebrate small events the dyad is experiencing during the hospital stays, such as the first latch of breastfeeding, the first bottle if a newborn cannot breastfeed, and when the newborn sleeps undisturbed for a few hours in a row. Nursing staff spend significant time reinforcing positive parenting and encouraging birth parents in the family-centered unit to participate in their newborn’s care. Whereas the nursing staff is the expert on neonatal care, the approach is that each parent is the expert in caring for their newborn. Nurses make care recommendations in huddles and reinforce with affirmative language to build upon families’ strengths.
Trauma Informed Care
Trauma informed care (TIC) is an anchor of the Nebraska Medicine model and considered an integral component of the core skill set for those working in the NICU and newborn nursery. Physicians, nurses, and members of the NICU team receive TIC training that prepares them to support the parents and infants in a safe manner through affirmative communications and collaborative care with the family.
Accessibility and Continuity of Care
A discharge coordinator monitors the development of the POSC to ensure that the mother and newborn will receive continuous care and appropriate services after discharge from the hospital. Working closely with neonatal providers, the discharge coordinator liaises with a pediatric medical home, pediatric and adult primary care providers, mental behavioral health service providers, and other community services for the family. The NICU discharge coordinator and the social worker access to the services and care families need during the hospital stay. Together, they document the appointments and referrals made for post-discharge care. Social workers collaborate with community partners and services to determine available benefits detailed in the POSC, such as transportation services for families to reach their appointments, breast pumps, and mental health services. They also instruct families on how to activate and access those services. To eliminate barriers to care the program encourages telehealth access as an option for mental health services when families return home and might have limited resources or no transportation to get to the appointments.
Financial Support and Billing
Financial support for NPQIC is received from grants and from the State of Nebraska. Staff time, including the time allocated to developing and beginning the implementation of a POSC, is funded from this operating budget. Within individual hospitals, the care for a birth parent is bundled together with the birth/delivery charge and the newborn care. Nebraska Medicine is committed to high-quality care for all parents and infants in the NICU; as such staff training to support parents in recovery and infants with NOWS is covered through the budget for professional development. The hospital utilizes ICD-10 codes (International Classification of Diseases) for diagnosis-related group reimbursement (DRG) for maternal and neonatal care. The hospital includes the costs of monitoring a newborn with NOWS into the billed neonatal DRG based on diagnosis and ICD-10 codes. Should a neonate need intensive care and medical therapy for NOWS care, then the hospital and provider costs are billed accordingly.