Rural Maternal Health Series: Achieving Birthing-Friendly Status in Rural Hospitals

Date: Tuesday, March 12, 2024
Duration: approximately 60 minutes

Featured Speakers

	Kristen Dillon, MD, FAAFP, Chief Medical Officer, Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services
	Stephanie L. Clark MD, MPH, MSHP, Medical Officer, Division of Quality Measurement (DQM), Quality Measurement and Value-Based Incentives Group (QMVIG), Center for Clinical Standards and Quality (CCSQ), Centers for Medicare & Medicaid Services
	Jacqueline Wallace MD, MPH, Perinatal & Infant Health Team, Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC)
	Cassie Phillips, MPH, Lead Public Health Analyst, Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services

“Birthing-Friendly” is a designation to describe high-quality maternity care and was launched by the Centers for Medicare and Medicaid Services (CMS) in the fall of 2023. To earn the designation, hospitals attest to meeting a 2-component measure established by CMS. With consideration for the specific context of rural healthcare and hospitals, speakers will introduce the Birthing Friendly measure and discuss the “why” and “how” of meeting it. For interested attendees, the next 2 webinars in the Rural Maternal Health Series will take a deeper dive into how hospitals can engage with their state Perinatal Quality Collaborative (PQCs) and standardize clinical care through implementing AIM patient safety bundles, developed by the Alliance for Innovation on Maternal Health.

Additional Resources

From This Webinar

Transcript

Kristine Sande: I'm Kristine Sande and I'm the program director of the Rural Health Information Hub. I'd like to welcome you to today's webinar. This is the first in a four-part series that we're hosting in collaboration with the Federal Office of Rural Health Policy on Rural Maternal Health. Today's webinar will focus on achieving birthing friendly status in rural hospitals. We've provided a copy of the slides on the RHIhub website, and that's accessible through the URL that shows on your screen. And now it's my pleasure to introduce our speakers for today's webinar.

First, we'll hear from Dr. Kristen Dillon. Dr. Dillon is a family physician with several decades of experience working in rural communities. She serves as the chief medical officer at the Federal Office of Rural Health Policy. Her responsibilities include advising on clinical care and the rural impacts of federal policy. In addition, she works with grantees, technical assistance providers, state offices of rural health, and other stakeholders to improve the stability and capacity of rural communities health systems.

Stephanie Clark is a pediatric nephrologist and medical officer in the Quality Measurement and Value-Based Incentives Group within the Center of Clinical Standards and Quality at CMS. She is the end stage renal disease measure lead and works on kidney related topics across CMS. In addition, she supports CMS's maternal health efforts along with a knowledgeable and passionate team of colleagues. She continues to see patients regularly at the Children's Hospital of Philadelphia.

Jacqueline Wallace is the medical officer for the statewide Perinatal Quality Collaborative Program at the Centers for Disease Control and Prevention. Dr. Wallace is an OBGYN physician with a deep commitment to women-centered care that respects ethnic and cultural diversity delivered through the lens of reproductive health as a human right. And our last speaker will be Cassie Phillips. She is the team lead within the maternal and women's health branch of the Division of Healthy Start and Perinatal Services within HRSA's Maternal and Child Health Bureau. Cassie leads the maternal health workforce and training team, which encompasses programs working to increase quality of care, the capacity of healthcare providers, and to set standards to advance maternal health in the United States. And with that, I'll turn it over to Dr. Dillon.

Kristen Dillon: Hello. Thank you all so much for joining us today. We can tell from the over 600 of you who registered for this webinar that there's strong commitment across our country to transform our rural healthcare system and achieve safer, higher quality care and better outcomes across pregnancy, birth, postpartum, and the newborn period. I want to thank my colleagues from within the US Federal Government's Department of Health and Human Services, and also our partners at Rural Health Information Hub for contributing to this series. Here at the Federal Office of Rural Health Policy, we have a specific role in improving health and healthcare for the one in five Americans who live in rural areas. So many of us are watching with alarm as the landscape from maternity care in rural communities changes. Based on recent CDC data, the rates of maternal death have risen over the past 30 years and death rates as of 2019 were highest in rural communities and small towns.

In rural communities, the risk of death was nearly double that of the lowest risk group, which was residents of suburban communities. So this happens in a context where many rural birth centers are closing in pairing access to optimal care. And it's for this reason that the final installment in our series on April 23rd will focus on strategies for hospitals that do not have birth units, how they can define and train to a scope of care that will optimize outcomes for pregnant, birthing, and postpartum patients who are still going to arrive at their facilities seeking help. From our office, we do see the many struggles that rural hospitals and healthcare providers face, finances, workforce, technology, extreme weather events, changing demographics. We understand all of the factors that compete for your time and attention, and that's why I'm so grateful that so many of you have chosen to join today to learn, and then we hope to improve and demonstrate your capacity to provide maternity care that's high quality, safe, and patient-centered.

I'm a practicing family physician. For nearly 20 years, I provided obstetrical care in rural critical access hospitals, and I've seen the amazing promise of close to home birthing services at such an important life transition for our patients. I've also experienced caring for patients during harrowing obstetrical and neonatal emergencies, many of which we could not have anticipated. I've seen the lifesaving potential of identifying complications early, preparing and practicing for emergencies, bringing consistency to our care practices, wherever that's appropriate, and learning to work as a team. And that's why we decided to focus the first three webinars in our maternity care series on the new CMS measure.

It evaluates hospitals on foundational competencies, learning collaboratively across a peer group and standardizing care processes. These are not check the box activities. Doing the work to meet this measure will help your staff do a better job and help your patients have confidence in the care you provide. They may take substantial work, but it's the work we need to be doing to improve outcomes for birthing people and babies in our country. So I couldn't be more pleased to have my colleague, Dr. Stephanie Clark, from the Centers for Medicare and Medicaid Services here today, and she's going to now share more about the birthing friendly hospital designation. Dr. Clark.

Stephanie Clark: Thank you so much, Dr. Dillon, and you really have the stage beautifully for us to talk a little bit more about the birthing friendly hospital designation and why it's so important to the patients that we serve and the newborns that we serve. So we'll talk first about the current designation. It's awarded to hospitals on an annual basis as part of the Hospital Compare Fall Refresh, which usually happens in October. The inaugural designations were awarded in October 2023. And really this designation builds on the White House blueprint for addressing the maternal health crisis. And as Dr. Dillon just eloquently said, we really truly do have a crisis. The designation is awarded the hospitals that positively attest to the maternal morbidity structural measure in the hospital inpatient quality reporting program for the prior calendar year. The maternal morbidity structural measure was developed by CMS in 2019 for the IQR program. It is a high priority for CMS to address the maternal health crisis.

And as you all know, increasing rates of severe maternal morbidity in the US nearly doubled from 1993 to 2014, and more than 50,000 women were affected by severe maternal morbidity in 2014. Again, truly a crisis. This measure was intended to fill a gap in which CMS did not have any hospital level measures addressing maternal morbidity. And again, this is the basis for the birthing friendly hospital designation. So before getting into more detail about the history of the maternal morbidity structural measure, I want to make note that two new electronic clinical quality measures for maternal health have been added to both the Hospital IQR and Promoting Interoperability Programs. I also just want to highlight these measures are not currently in the birthing friendly designation. These measures, again, are eCQMs, and the first one is severe obstetrics complications, excuse me, measures the proportion of patients with severe obstetrical complications that occur during the inpatient delivery hospitalization.

The second of the two is the cesarean birth eCQM. It measures the rate of nulliparous women with a term singleton baby in a vertex position delivered by C-section. And just to note that the voluntary reporting was for calendar year 2023 and mandatory reporting started with calendar year 2024. I also want to highlight that both of these measures are in the Promoting Interoperability Program and so would apply to critical access hospitals. So just to go back to the maternal morbidity structural measure conceptualization initially, the goal was to develop a structural measure that incentivized hospitals to engage in meaningful quality improvement to reduce maternal morbidity. The aims were participation in a quality improvement initiative aimed at improving maternal outcomes during inpatient labor, delivery, and postpartum care. We wanted a specific focus on morbidities known to be associated with mortality and low burden. Other considerations, including state-based and national quality improvement initiatives, could be advantageous to hospitals resulting in improved quality quickly, just like Dr. Dillon mentioned.

And I just want to say that the maternal morbidity structural measure in its current form is a starting place. It's the first step in what we hope will be a robust designation with additional measures and domains in the future. This could include modification of the structural measure, addition of those two new eCQMs as well as patient reported outcome and experience measures. And so again, we hope that this is the first step and will continue to move forward from here. And I have put the maternal morbidity structural measure question up on the screen just so that you can see it. It asks hospitals, "Does your hospital or health system participate in a statewide and or national perinatal quality improvement collaborative program aimed at improving maternal outcomes during inpatient labor delivery and postpartum care and has it implemented patient safety practices or bundles related to maternal morbidity to address complications including but not limited to hemorrhage, severe hypertension or preeclampsia or sepsis?"

You then can choose yes, no, or not applicable if your hospital does not provide inpatient labor or delivery care. In terms of measure reporting, hospitals report this measure to CMS on an annual basis with regard to their maternal health efforts for the prior calendar year. They submit these responses once a year via a CMS approved web-based tool within the HQR Secure Portal. The reporting period runs from January 1st through December 31st of a given measurement year, and then the submission period for that data runs from April 1st through May 15th following the year of the applicable reporting period. If you'd like more information on the maternal morbidity structural measure, it's available on the web-based data collection page of CMS's QualityNet website. On that page, you can also have access to the Maternal Morbidity Structural Measure Quick Reference Guide, as well as a frequently asked questions document. And I also just want to highlight for you all because I think it'll be very helpful that an attestation guide is in developments and will soon be posted, and we really hope that it'll be posted by the end of March.

Just to touch on perinatal quality improvement collaboratives and what counts as your involvement in that, they can be national or state-based, hospitals must be actively engaged in maternal and child health quality improvement activities, established and coordinated by the collaborative, including implementation of patient care safety practices and or bundles in conjunction with the collaborative. And some examples of collaboratives are the CDC's National Network of Perinatal Quality Collaboratives, HRSA's Alliance for Innovation on Maternal Health Program, and the California Maternal Quality Care Collaborative. And just to bring us back to the focus on rural hospitals, in full transparency, we don't yet have a full picture. Critical access hospitals are not required to participate in the Hospital IQR program, but can voluntarily report this data and receive the designation. As of 2023, 470 critical access hospitals did voluntarily report. And so we hope that as we move forward, we'll get a more full picture of how this is affecting rural hospitals. And with that, I will pass it on to Dr. Wallace. Thank you so much for the opportunity to be with you today.

Jacqueline Wallace: Good afternoon everyone. It is really such a pleasure to be here today. As was mentioned, my name is Jackie Wallace and I'm the medical officer for the Perinatal Quality Collaborative Program in the Division of Reproductive Health at the CDC. And this afternoon I'm going to share just some basic information about the state Perinatal Quality Collaboratives or PQCs that Dr. Clark alluded to. So in the next 10 minutes, I'll give a broad overview of the state PQCs. We'll just start with the basics, kind of who, what, how. We'll talk a little bit about the different structures of PQCs, what they have in common, how they're different, the issues that they're working on. We can talk a little bit about some of the results that they've achieved and touch then briefly on how PQCs fit into the more general landscape of maternal child health and more specifically how they align with AIM and with just a little bit on PQCs into the future.

So what is a PQC? A PQC is a state or multi-state network of multidisciplinary teams. And typically the team includes perinatal care providers, public health professionals, community members, community-based organizations, outpatient providers, all working together to improve maternal and infant outcomes across the state. And the way that they do this is through using quality improvement methods and typically, traditionally, PQCs work at the hospital level. So in the hospitals. So essentially a PQC is an organization working across the state, convening stakeholders, engaging hospitals, providing technical assistance to hospitals as the hospitals work to improve their care processes. So what does that mean supporting hospitals to implement QI? So as a process, typically, a PQC QI initiative includes three pillars that include collaborative learning, rapid response data, and a QI science support. So almost every PQC will have a collaborative learning model. Typically, they'll bring hospital teams together, almost always virtually to provide education.

They'll host webinars series, they'll sometimes do in-person meetings, in-person simulation trainings, but really leaning into collaborative learning. So there's a lot of the hospital teams sharing with each other. There are challenges, there are successes, really learning from each other. There's also an emphasis on rapid response data. So there's a lot of variation in how the data's collected. Sometimes hospitals will submit data directly to the PQC or hospitals will sometimes submit data to the hospital association or to the state department of health. And that gets back to the PQC. The PQC will typically analyze the data and then feed it back rapidly to the hospital so you can base actions on that information. And then the PQCs also provide QI science support.

So most PQCs will use a Plan-Do-Study-Act type of QI method. So it's a very rapid iteration of you plan a change, you implement the change. Sometimes only just with one patient, you study the change and then you act on the information that you get. Maybe everything's working really well, you scale up the change or maybe you make some little tweaks to the process. So that's typically what happens in a QI initiative. So where are these activities happening? Everywhere. There is a PQC now in every state, although the PQCs have varying levels of experience. So there are PQC activities happening basically in every state.

The oldest PQC was formed in the late '90s, and the newest PQC was formed in 2024. So you can see there's quite a variety in experience. CDC does support PQCs. Currently, we are supporting 36 PQCs as well as the National Network of PQCs. The National Network is like a technical assistance center for PQCs. So while there are PQC activities in every state, it's really important to understand that there are some large differences between the PQCs. As I already mentioned, some differences in experience. There are differences in structure, in staffing and activities. So they really are as unique as the states that have created them. So let's dive into that just a little bit.

There's a real variety in where the PQCs are housed. So about a third of PQCs are housed within an academic institution, about a third are housed within a state department of health, about 10 to 12% are within a nonprofit organization. There are about five-ish percent that are in a hospital association. And then there are several PQCs, I should say, that are partnerships. So it might be an academic institution partnered with a state department of health or a triumvirate with an academic institution and a nonprofit and the state department of health. So there's a lot of variety and it can make it difficult to find the PQC if you would like to find out where they are and you want to partner with them. But we'll talk about that at the end. There are definitely ways to track them down.

It's probably pretty obvious that where a PQC is located can have a big impact on how they function. Some processes may work much faster in a nonprofit and not so much in a state department of health and an academic institution may have different resources than say a hospital association. So what are PQCs doing? So there's a wide variety of activities. This is a list of some of the more common initiatives that are going on. Really currently, one of the most common initiatives being implemented is care for pregnant and postpartum people and newborns affected by substance use disorder. Also, cardiac conditions and hypertensive disease. There are quite a few PQCs that are working on specific birth equity initiatives, as well as some PQCs that are working solely on neonatal initiatives. Reduction of low risk C-sections, supportive vaginal birth. And these are all initiatives that are really front and center for many PQCs.

And I should mention, most PQCs are working on more than one initiative. They may have one or two in an active phase, some might be in pilot phase, some might be in the sustainability phase. So let's take a brief look at some of the results of some of the PQC work. So in North Carolina, the PQC was able to reduce central line associated infections among newborns in the NICU by about 71%. In Illinois, the PQC improved timely treatment for women with severe hypertension, increasing the percentage of patients who were adequately treated from 41% at baseline to 79% in the first year of their project. And the Louisiana PQC was able to have an impact on some of the health outcome disparities. They were able to decrease severe maternal morbidity from hemorrhage. In Black women, they reduced this morbidity by 49% and overall by 35%. So working on reducing the health outcome disparity in that population.

So let's transition. We talked a little bit about the who, what, how of PQCs, like that's just briefly look at how they fit into the maternal child health landscape. Obviously there are lots and lots of people who are passionate about improving maternity care in the US. It's really partnerships, collaboration, sharing is what makes the PQC model so successful. This is just a smattering of some of the organizations that partner with PQCs. It's by no means a comprehensive list, but PQCs along with AIM partner with state Maternal Mortality Review Committees with maternal health and innovation programs, with state departments of health, with hospitals, community health centers, individual providers as well as patients, families, communities, community-based organizations and people with lived experience. And we need everyone at the table in order to move the needle on this important, important issue, this crisis. All right, so let's talk a little bit about PQCs and AIM.

And I'm just going to briefly touch on this because we're going to be hearing about that in much more detail in just a moment. But there is often a lot of confusion about what's the difference between AIM and PQCs. So they're very closely aligned, but we are different programs. AIM develops the patient safety bundles for specific clinical conditions and a patient safety bundle I really think about it as it's a map. It's a map of how to improve care processes to manage OB conditions and complications. And so the AIM patient safety bundles are one of the tools in the PQC toolbox. PQCs implement AIM bundles. They use other AIM resources in hospitals or across their state. Sometimes PQCs develop their own bundles or they might implement neonatal initiatives, as I mentioned. And PQCs are increasingly conducting activities outside of the hospital. But essentially PQCs are the implementation arm of the AIM patient safety bundles.

What's coming in the future? So from our perspective, we're really emphasizing that PQCs should incorporate health equity into every activity that they're doing. We're encouraging the PQCs to start to move beyond the hospital to engage community-based facilities and providers to break down the silos, really looking to increase engagement with patients, families, and people with lived experience and increasing partnerships with the MMRCs, the Maternal Mortality Review Committees and other federal, state, and local organizations.

So finishing up, PQCs really are essential. They're making change happen at the local level, the local hospital patient provider level, but they have the infrastructure to really scale this up statewide, really have the power to bring partners together to collaborate. And really CDC as the supporter of PQCs, HRSA as the supporter of AIM, we're also working really closely to align the efforts of our programs but not duplicate each other because really the ideal is that we need to amplify the work, amplify each other's efforts in order to tackle this crisis. I would be happy to answer any questions, either contact me directly if you need help finding your PQC, please reach out. And at this time it's my pleasure to hand the stage over to my colleague, Cassie Phillips, with HRSA.

Cassie Phillips: Good afternoon. I just want to say a word of thanks to the Federal Office of Rural Health Policy for pulling together this webinar series and appreciate the time to shed a little more light on the AIM bundles, which we've started to hear a little bit more about. So hopefully by the end of this, you'll have a clear understanding of all these acronyms and what they mean. So as I stated, my name's Cassie Phillips. I'm a team lead within the Maternal and Women's Health Branch and within my team, one of the programs that we work on is the Alliance for Innovation on Maternal Health. The AIM program is the national, cross-sector commitment designed to lead in the identification, development, implementation, and dissemination of maternal patient safety bundles for the promotion of safe care for every US birth and assist with addressing the complex problem of high maternal mortality and severe maternal morbidity rates within the United States.

And this is really achieved through engaging multidisciplinary partners at the national, state, and local level, developing and providing tools for implementation of evidence-informed patient safety bundles, utilizing data-driven quality improvement strategies, and aligning existing efforts and dissemination of evidence informed resources. AIM is really the what, it's the tool that folks are using to do this work. And the tool are these things called patient safety bundles. So the core building block of the AIM program and its efforts to address this are the bundles and there are eight of them. And these bundles are collections of evidence informed best practices that are developed by a multidisciplinary team of experts. And each bundle addresses a clinically specific condition in pregnant and postpartum people. And each bundle has various strategies aimed at improving care processes that lead to improved clinical outcomes. So since 2021, all bundles have either been developed or updated to include strategies that focus on promoting respectful, equitable and supportive care.

And each bundle has a section on respectful care that is meant to highlight best practices in offering and providing such care to every patient in every setting from every provider. So a little bit more about that bundle structure, regardless of which of the eight bundles you're looking at, you're going to see them organized around what was initially a four R structure. And then we added the fifth R to achieve this cultural shift in resulting improvements in maternal health outcomes.

So the first R is around readiness with the idea that every unit is prepared and educated. So this looks like staff drills on emergency situations, learning to work as a team, conducting debriefings and refining your processes and techniques and that with the idea that delivery units are ready with accessible medications, instrumentation, and standard protocols.

The second R is recognition and prevention. So this is applied for every patient before an event. We would like optimum recognition of maternal risk early to facilitate transfer to high risk women to facilities with the equipment and staff that are appropriate to handle potential problems and to ensure that health providers have the appropriate consultation and mentors available.

The third R is response. So the response for every event within a team approach. So early warning signs of maternal distress is critical both within labor and delivery units as well as in the emergency room. So every facility should have protocols on acceptable response times for how quickly senior medical personnel to be at the bedside to assess the woman in the case of hemorrhage, for example, cumulative blood loss is measured and everyone who's involved in the severe maternal event, including the medical staff, the family and the woman herself are debriefed and supported.

And then the fourth R is reporting systems learning. So this is for every unit to engage around that systems improvement. So reviews of the events and reporting are accomplished in a multidisciplinary manner to improve unit learning on any actions and outcomes that are related to that event. So the reviews are really important to make systemic changes and to educate others in the healthcare and public health system.

And then as I mentioned, we added a fifth R for respectful, equitable and supportive care to integrate elements into each bundle that focus on having equitable care within the unit provider and team member levels.

So you've heard some of the bundles, but just for your awareness and to demonstrate the connection between the leading causes of pregnancy related death and the AIM program, I'm just going to run through what the eight bundles actually are. So we have a bundle to address obstetric hemorrhage and severe hypertension in pregnancy. There's a bundle targeted at the safe reduction of primary cesarean birth and care for pregnant and postpartum people with substance use disorder.

We have a bundle that addresses perinatal mental health conditions and postpartum discharge transition. And finally bundles focused on cardiac conditions and sepsis and obstetric care. And all of these bundles are available and free to download on the AIM website, which is SaferBirth.org. And I have it on my final slide.

AIM engages and really requires and needs stakeholders at the national, state, and local level. So nationally in fiscal year 2023, HRSA funded the American College of Obstetricians and Gynecologists or ACOG as the AIM TA center. And they're charged with providing technical assistance to all jurisdictions who are implementing AIM bundles. So anyone, regardless of who you are, who's interested in engaging on this work can reach out and receive technical assistance from the AIM TA center. And they also work with a lot of doing a lot of the items that you see bulleted in this slide. At the state level, as was mentioned by Dr. Wallace, we often see Perinatal Quality Collaboratives or other such QI leaders in a state spearhead AIM activities across the state to support birthing facilities in implementing bundles and then sharing tools and resources to assist in data reporting.

And in FY '23, HRSA directly funded 28 states jurisdictions and territories to support AIM implementation at that state level. And then finally at the local level, the bundles are themselves implemented at the birthing facility level and that often involves hospital staff, QI leaders and patients to implement bundles and then collect the data which informs the rapid quality improvement cycles that underpin bundle implementation. And I would just also underscore, I know the audience is a large number of rural and critical access hospitals. The bundles are intended to be implemented in birthing facilities and aren't necessarily structured to be adapted to non-birthing facilities. I think that's an important caveat I want to share. The AIM bundles are currently being implemented nationwide with 49 states plus the District of Columbia and Puerto Rico formally enrolled in AIM. But we do have birthing facilities in all 50 states implementing bundles.

And these are just some examples of the impact of AIM among birthing facilities. So you can see in Alaska there was a 22% increase in timely care for pregnant people with persistent severe hypertension. In Georgia, the proportion of hospitals with obstetric hemorrhage carts readily available increase from 49% to 96%. In Illinois, pregnant or postpartum people with opioid use disorder or connected to opioid use disorder medication by delivery discharge increasing from 41% to 76%. And in New York, participating facilities in AIM had a universal screening protocol for substance use disorder increased from 33% to 86%. So that's just a flavor of some of the outcomes that we've been really pleased to see occur with bundle implementation. So I just want to thank everyone for their attention and time. Please feel free to reach out to me or the AIM TA Center, which is the SaferBirth.org website if you have any questions or happy to answer questions with the time that we have left.

Kristine Sande: Thanks so much to all our speakers for those great presentations. We do have one question in the Q and A box already, and I believe this is for Cassie. Have you encountered any hospitals with shuttered OB units who are reluctant to adopt ER appropriate bundles based on recommendations from their liability carrier?

Cassie Phillips: I wouldn't say I personally have, but I know that this circumstance applied to a lot of facilities. I would just say that there aren't ER bundles per se. There are bundles that ask for birthing facilities to engage with emergency departments for transitions, for identification of early warning signs, et cetera. But it wouldn't be that bundle is being implemented in an ER facility as a standalone project. And with the shuttering of so many OB units outside of the bundle structure, the AIM program has developed some other resources and toolkits around obstetric readiness for non-birthing facilities. And so I would point you to the AIM website to look at that OB readiness toolkit, but that's not a bundle per se. So I hope that addresses the question. And I don't know, I saw Dr. Wallace come on camera, so I don't know if she has anything she wants to add.

Jacqueline Wallace: No. Thanks, Cassie. I just wanted to mention the OB readiness toolkit and the information that recently went live through ACOG, the American College of OBGYN. And thank you for the question. It seems to me that that's the exact opposite of what you want to be doing. It makes my head want to explode to think that a liability carrier is saying that you shouldn't implement better care because of liability. So let's not go there. But I would highly recommend that you look at the tools that are available on AIM and ACOG because the patients are coming anyway, right? The patients are going to show up in your emergency department anyway. So would really encourage you to use those tools to improve the processes of care.

Kristine Sande: Right. Thank you. And the last webinar in this series is going to be on OB Ready for hospitals that don't have labor and delivery. So hopefully people will tune into that one too. There's a couple of questions about funding and reimbursement. So will there be a reimbursement tied to the birthing friendly designation for critical access hospitals? And is there funding being allocated for these endeavors more generally? So would someone like to answer that question or questions?

Stephanie Clark: I can start with the first part. So critical access hospitals are not required to report for the birthing friendly hospital designation. And so there is no payment tied to that and certainly there's not going to be reimbursement from CMS, but I'll let Dr. Dillon take over the rest of that question.

Kristen Dillon: Sure. And in terms of support for making progress, our office, the Federal Office of Rural Health Policy, supports the State Offices of Rural Health and a program of grants that we call the Flex grants, which often go to the office of rural health or a related organization in each of the states with critical access hospitals. And we are actively encouraging our Flex grantees to move forward on maternal health, including in this area. And we have added the birthing friendly hospital designation as one of our recommended supplemental measures for our critical access hospital quality improvement program. So we're actively moving forward with both the encouragement and the technical support to have a rural hospitals move in this direction.

Cassie Phillips: And I can just add on, as I mentioned in FY '23, so last fiscal year, MCHB within HRSA funded 28 states to implement AIM bundles. And part of that AIM bundle capacity program was to increase the number of facilities participating in AIM. It really varies from state to state the number of facilities that are engaging in AIM work. And so that's new funding that's been made available. And we don't have a budget for FY '24 yet, but I would just stay tuned because there might be more opportunities in subsequent years for our additional states to receive that funding.

And we also have a number of other funding opportunities that we put out to states around maternal health innovation and maternal health work that at the state level is supposed to engage hospitals and all partners in maternal health to advance this work. And so it may not be AIM specific, but it's inclusive of AIM. And that program, the State Maternal Health Innovation Program is currently active in 35 states and there's an open award for that that's being competed and closes on April 2nd. And so we're hoping to add somewhere to the tune of 12 more states. And so I think there's funding at different layers available to support this work.

Kristine Sande: Another question is how do we start to voluntarily report information that way we could work towards this? Is there a way to do that?

Stephanie Clark: Yes, great question. I'm actually going to post a link in the chat that you can actually go on that link and sign up to voluntarily report by completing a notice of participation. So I'll drop that link in the chat.

Kristine Sande: All right. Another question was asked, can I attest now for the designation or is it only open for a certain period of time within the HQR? Stephanie, would you want to answer that?

Stephanie Clark: Absolutely. And so this is also in the slide so you can refer back to it, but the submission period is April 1st through May 15th of the year following the calendar year of reporting. And so for 2023, the submission period will open on April 1st and will close on May 15th. And also, just to clarify that the link that I dropped in the chat, you do have to log into the HQR program first or site first and then you'll be able to do the participation.

Kristine Sande: So, for each bundle, are there national or state target levels a facility should aim for?

Cassie Phillips: I think the answer in short is no. I mean we are trying to just trend upwards. So to improve, it's quality improvement, it's a continuous cycle. I don't know if we'll ever get to a hundred percent if a hundred percent is the number, but the goal is just for AIM to increase the number of facilities that are implementing quality improvement like the bundles. And then Dr. Wallace alluded to sustaining bundles because there's so much turnover and change in the staffing. Oftentimes we find that maybe gains are made, but are they able to be sustained? So there's ongoing monitoring of that initiative to make sure that it is being sustained. And I think that that's an enduring effort.

Kristen Dillon: And I'll just add that in our work in HRSA with critical access hospitals, rural hospitals, we're looking for the same thing at this point, which is improvement. And honestly, even also just having a higher and higher numbers of critical access hospitals report because even if hospitals aren't able to attest to the measure yet reporting and giving us their status helps us fine tune our technical assistance and our outreach. A big reason this webinar came about is some outreach and surveys we did that just identified that the number one need was just education. And so we really just appreciate everyone learning about the measure and then over time we want to see improvement in reporting and performance.

Kristine Sande: All right. So for Jackie, I believe, so the question is to understand better with our small critical access hospital, what would we encounter since the CDC doesn't provide funding in our state?

Jacqueline Wallace: There is a PQC in every state. And so regardless of where they're getting their funding from, you could still partner with your PQC is the short answer.

Kristine Sande: Okay.

Jacqueline Wallace: Yeah, and I didn't mention, one way to find the PQCs is to go to the National Network website, the nnpqc.org, and they have a map, so you can click on the map and that would also point you in the right direction. And most PQCs have multiple lines of funding. So even if CDC is not able at this point, I mean at some point, hopefully we can fund all 50, but the work is still going on.

Kristine Sande: All right. And what recommendations do you have to facilitate PQC and AIM engagement in rural hospitals that have minimal resources to spare, which is not unusual?

Jacqueline Wallace: I can take that as well. Well, please come to the next webinar because we're going to be talking to a couple of PQCs that have successful partnerships with rural hospitals. And so they may have some insights in how to facilitate engagement. But I would encourage you to just reach out. There are different levels, many PQCs, many states have different levels of engagement and they're quite aware that rural hospitals are really lacking in resources and so can be flexible in working with you to the best of your ability knowing that everybody is struggling with lack of resources, lack of staff. And so please don't hesitate to still reach out to the state PQC.

Cassie Phillips: And I would just add within the AIM bundles, there are the bundle elements that call out like what are the goals or the evidence-based recommendations and best practices to implement. But there's flexibility within that and they can be adapted to the different resource levels in different settings. And we have seen AIM bundle successfully implemented in rural settings. And so I just want to say that the AIM bundles themselves are also adaptable and flexible to some degree.

Kristine Sande: So if your facility participates in AIM and maintains those bundles and standards after your facility is done reporting data to AIM, does it still count as participating in a project?

Stephanie Clark: So I think that that will be clarified in the attestation guide and there needs to be ongoing work with the collaborative for it to count. But that will be addressed in the upcoming attestation guide.

Kristine Sande: Is there guidance within the bundles for how to leverage or collaborate with state psychiatric access programs?

Cassie Phillips: I can't specifically say yes, but I'm inclined to say yes. All of the bundles elements come with companion documents about resources and examples, and there's a wealth of resources to support that. And I would say if you don't find that within the bundle package that you can download, please reach out to the AIM TA center to get more information and support. They'd be happy to work with you on that specific topic.

Kristine Sande: Sorry. Will the birthing friendly hospital designation eventually become mandatory for critical access hospitals? And if so, is there a timeframe for that?

Stephanie Clark: Thank you so much for the question. So the Hospital IQR program eligibility excludes critical access hospitals, and that's actually determined by statute. So it would require an act of Congress to change that eligibility, so that would have to essentially require an act of Congress for that to change. So no timeline on that.

Kristine Sande: So this I believe is a follow-up question to an earlier question about measurements and targets. It says, "But the goal could be X percent in improvement following implementation, but if there's no way to measure the bundles, how do you know success can be attributed to the bundle?" Cassie, did you want to answer that?

Cassie Phillips: Yeah, so there's a huge data component to AIM bundle implementation. So each of these elements within a bundle have specific process structure and outcome measures. And part of the rapid quality improvement cycles is collecting the data and monitoring to see if there's change in your way of providing care or whatever you're implementing. And so I would say maybe the target is just benchmarking against yourself, so you collect your own data and it's a quality improvement process. So you then over small tests of time, see how you're making improvement. So while there's no, let's say, national benchmark that we're pushing you towards, it's just that continuous quality improvement and you're using the data that you collect on whatever bundles you're implementing, and we provide you the bundles themselves, have the specific metrics that you are to report on to support that.

Kristine Sande: I'd like to thank you all for joining us today and thanks so much to our speakers for sharing this great information with us. The slides used in today's webinar are currently available at www.ruralhealthinfo.org/webinars. In addition, a recording and transcript of today's webinar will be made available in the RHIhub website. Thanks so much for joining us and have a great day.