Boston Medical Centers Labor and Delivery Collaborative Model

Boston Medical Center’s Labor and Delivery Collaborative Model Richard Long, Jennifer Pfau, Jordana Price and Michelle Sia Boston University School of Medicine Department of Family Medicine Department of Obstetrics and Gynecology April 2016 STFM

Disclosures • Nothing to Disclose

Boston Medical Center • New England’s largest safety net hospital • 496 -bed academic medical center • 75% of patients are from underserved populations • 31% of patients do not speak English as a primary language

History of the Collaborative Model at Boston Medical Center • 1996 -2006 discontinuous FM attending and resident coverage • 2006 - 24 -hour presence/coverage by Family Medicine attending on Labor and Delivery • 2007 - Institution of new algorithm for distribution of patients between OB/Midwifery/Family Medicine services • Keys to success= merged billing, interdisciplinary approach to patient care, focus on individual skill sets Pecci et al. How We Built Our Team: Collaborating with Partners to Strengthen Skills in Pregnancy, Delivery, and Newborn Care. J Am Board Fam Med 2012; 25: 511– 521.

Boston University Medical Center Family Medicine Residency Program • 10 residents per year (2011) • Divided among 3 primary clinical CHC sites -Codman Square Community Health Center -East Boston Neighborhood Health Center -South Boston Community Health Center • Faculty practices at multiple sites

MCH Faculty- Department of Family Medicine • Non-fellowship trained= 13 providers • Fellowship trained= 5 providers • 12 -hour in-house shifts, 365/24/7 coverage • Supervise/teach Family Medicine, OB, ED residents (in addition to Pediatric residents on the well baby unit/pediatric inpatient floor)

Total OB Volume and Volume by Service

FM, CNM and OB Delivery Volume

CS and NVD by Service: FM and OB OB CS FM NVD 547 OB NVD 372 FM CS % CS by FM AND covered the Postpartum Service (MBS)! Total of 1, 433 CSs in 6 years

Deliveries by Health Center 12/1/2014 -11/30/2015 Prenatal Site Term # Births BMC Preterm % # Births NA % #Births Total % Percentage Of Total Births 1, 001 86% 158 14% 0 0% 1, 159 46% Codman Square 122 89% 15 11% 0 0% 137 5% Dorchester House 93 89% 12 11% 0 0% 105 4% 743 94% 46 6% 0 0% 789 31% 2 100% 0 0% 2 0% Mattapan 46 90% 5 10% 0 0% 51 2% Roslindale 25 96% 1 4% 0 0% 26 1% South Boston 43 96% 2 4% 0 0% 45 2% South End 14 100% 0 0% 14 1% Upham's Corner 75 95% 4 5% 0 0% 79 3% Whittier Street 45 92% 4 8% 0 0% 49 2% Other 42 72% 16 28% 0 0% 58 2% 5 50% 0 0% 10 0% 2, 256 89% 268 11% 0 0% 2, 524 100% East Boston Harvard Street No Prenatal Grand Total

BU Collaborative Model • How do we teach this to residents? • MCH Core Curriculum • FM Process Integration • RN, CNM, OB role in FM residents’ education • FM, RN, CNM role in OB residents’ education

MCH Curriculum • • ALSO course (new PGY 2) Teams Training (new PGY 1) 1: 4 Wednesday PM seminar 1: 4 Monday PM resident lectures 1: 4 monthly M&M (MCH) Gnosis EFM training (annual, collaborative) OB simulations (1 -2/yr, collaborative) Clinical Experience -L&D -Mother Baby Service

FM Process Integration • FM participation on OB QAI committee, Perinatal Committee, Perinatal Safety Committee, Simulation Committee (several include nursing participation) • Interdisciplinary rounds every shift • Interdisciplinary Case Reviews • Teams Training • FM & OB residents share responsibilities on L&D • Demonstration of collaborative care, teaching and learning

BU Collaborative Model How do we evaluate how we teach it? • In-Service exam scores • # residents including maternity care in postgraduate practices/ fellowship • Resident delivery distribution per provider discipline supervising/teaching • Resident evaluations/ Faculty evaluations • 360° evaluation

FM Resident Deliveries by Attending 2015 • 505 NVDs • 263 (52. 1%) supervised by CNM • 184 (36. 4%) supervised by FM • 58 (11. 5%) supervised by OB 12 C-sections • 5 (41. 7%) supervised by FM • 7 (58. 3%) supervised by OB • 2578 deliveries at BMC; 992 OB deliveries (372 NVD and 620 C-sec), 834 by CNMs and 752 FM deliveries (547 NVD, 205 C-sec) *OB and ED resident delivery data is not reported

Family Medicine Residency Graduates- OB Experience After Graduation L&D Care in first Job Graduation (including MCH Year Total graduates fellows) MCH Fellowship 2 1 0 2001 6 4 0 2002 6 0 0 2003 6 0 0 2004 6 0 0 2005 6 1 0 2006 6 3 0 2007 6 1 1 2008 6 2 1 2009 6 3 0 2010 6 2 2 2011 6 1 0 2012 6 1 0 2013 10 1 1 2014 9 3 1 2015

Answers to In-Training Exam Maternity Care Questions In-Training Exam. Percent Maternity. Correct Questions 100, 00% 90, 00% 80, 00% Percent Correct Answers 70, 00% 60, 00% 50, 00% 40, 00% 30, 00% 20, 00% 10, 00% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 All BMC Residents 83, 33% 56, 92% 64, 29% 63, 37% 60, 44% 66, 18% 72, 22% 64, 37% 61, 67% 49, 43% 86, 29% 72, 14% 75, 89% 65, 02% All FM Residents 76, 40% 59, 62% 65, 93% 67, 19% 62, 94% 64, 57% 69, 26% 64, 37% 57, 16% 54, 67% 78, 21% 67, 76% 61, 63% 55, 57% Year

BU Collaborative Model How else do we teach this to residents? How else can we evaluate how we teach it? That’s why we’re all here. We will help each other teach and evaluate better! Thank you!

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