Missouri is Bringing Risk Appropriate Care to its Moms and Babies

Posted September 20, 2016 by Josh Grant

Infant Resting In NICU
Risk appropriate care in Missouri can ensure that babies receive the right treatments
on time. 

This post is in support of Infant Mortality Awareness Month, a great opportunity for everyone from patients to healthcare providers to think about how they can contribute to better health outcomes for infants around the country. 

Designation levels for hospitals about their perinatal care capacity were created to increase the likelihood that moms and babies are cared for at hospitals that provided risk appropriate services. In some states like Missouri, hospitals are allowed to self-designate their levels of neonatal and maternal care, but that can often create misrepresentations of care for various healthcare issues, such as very low birth weight for babies or cardiac complications for moms.

However, as part of the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN), Missouri aims to move the state’s hospitals away from self-designation to better support perinatal regionalization—the idea that a system exists to designate where babies are born or transferred according to the level of care they need at birth—and improve health outcomes for moms and babies.

“There is a 40-year body of literature and evidence showing that perinatal regionalization is effective in improving birth outcomes,” says Trina Ragain, MSPH, maternal child health program impact leader at the Missouri chapter of the March of Dimes and Missouri IM CoIIN team member. “Our first goal is to create a formal designation process like the ones used in many other states.”

The uniformity will help clarify the requirements hospitals need to meet for specific levels of care. Currently with self-designation, some facilities are using 2008 guidelines and others are using 2012 guidelines. Combined with each hospital’s own interpretation of these standards, Missouri now has 17 centers that self-designate as Level 3 neonatal intensive care units (NICU) or higher; there’s no way to know how many of these facilities meet any, some or all of the requirements for Level 3 care with self-designation. 

Improper levels of care can increase the risk for infant mortality. According to 2014 data from the Missouri Department of Health & Senior Services, there were 6.49 infant deaths per 1,000 live births in Missouri between 2010 – 2012.

“Formalizing designations for different levels of care protects moms and infants by ensuring that providers know which facilities can provide the right services for every patient,” says Pat Heinrich, RN, MSN, CLE, executive project director at NICHQ. “The move towards regionalization and strict requirements for levels of care is an important step in improving how Missouri’s moms and babies receive appropriate interventions.”

Using Regions to Improve Urban and Rural Care

Academic centers and higher level hospitals in urban St. Louis and Kansas City were some of the early champions for improvements to Missouri’s risk appropriate care designations. One of the challenges has been engaging rural hospitals in what a formal designation process would like look and how it would affect them.

Because Medicaid wasn’t expanded in Missouri, many rural hospitals cut labor and delivery units because they couldn’t financially sustain them. As a result, there are two areas of over 100 square miles without a hospital that delivers babies or provides perinatal care. For rural facilities that still provide perinatal care and deliver babies, there was concern that regionalization was an attempt to keep them from continuing those services.

“We’re really addressing that perception, because we need the 68 hospitals that deliver babies to keep delivering babies, especially in those underserved areas,” says Ragain. “This effort is about understanding every hospital’s capabilities and linking resources in every region to provide hospitals with more support so moms and babies receive the best possible care.”

The goal is to create regions and set up boundaries, while also accounting for the geographic proximity of hospitals, the commonality of maternal and child health (MCH) issues in different areas, and hospitals’ preference to have flexibility on where they can send their patients for more specialized care. The Missouri IM CoIIN team reached out to different states to learn about how they designed their systems; Texas was especially helpful as a model for proposed legislation because it regionalized in 2013, making it one of the more recent states to do so.

Beyond IM CoIIN, Missouri’s team is far from alone in its effort to regionalize perinatal care. The Missouri Children’s Services Commission’s Prematurity & Infant Mortality Subcommittee, which is chaired by Ragain, includes representatives from myriad partners, including the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, and the Missouri Department of Health & Senior Services among others. Within Missouri’s MCH community, the work of the CoIIN team, the subcommittee and Title V stakeholders is being combined to create a united voice on issues like perinatal regionalization.

As the formal designation process is created, there has already been some success among hospitals. Ragain notes that many hospitals are much more familiar with the levels of care and are starting to recognize that they don’t meet some of the requirements for their self-designated levels.

“They’re starting to adjust their designations as a result,” says Ragain. “Until we have a formal process mandated through the state, that’s very important for how they serve patients, and making those changes now will help them meet the criteria for specific care levels once regionalization goes into effect.”


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