Journal of Midwifery & Women’s Health
www.jmwh.org
Original Review
CenteringParenting: An Innovative Dyad Model for Group Mother-Infant Care
CEU
Joanna Bloomfield, MPH, Sharon Schindler Rising, CNM, MSN
CenteringParenting is a group model that brings a cohort of 6 to 7 mothers and infants together for care during the first year of life. During 9 group sessions the clinician provides well-baby care and also attends to the health, development, and safety issues of the mother. Ideally, CenteringParenting provides continuity of care for a cohort of women who have received care in CenteringPregnancy, group prenatal care that is 10 sessions throughout the entire pregnancy and that leads to community building, better health outcomes, and increased satisfaction with prenatal care. The postpartum year affects the entire family, but especially the mother, who is redefining herself and her own personal goals. Issues of weight/body image, breastfeeding, depression, contraception, and relationship issues all may surface. In traditional care, health resources for support and intervention are frequently lacking or unavailable. Women’s health clinicians also note the loss of contact with women they have followed during the prenatal period, often not seeing a woman again until she returns for another pregnancy. CenteringParenting recognizes that the health of the mother is tied to the health of the infant and that assessment and interventions are more appropriate and efficient when done in a dyad context. Facilitative leadership, rather than didactic education, encourages women to fully engage in their care, to raise issues of importance to them, and to discuss concerns within an atmosphere that allows for the surfacing of culturally appropriate values and beliefs. Implementing the model calls for system changes that are often significant. It also requires the building of a substantial team relationship among care providers. This overview describes the CenteringParenting mother-infant dyad care model with special focus on the mother and reviews the perspectives and experiences of staff from several practice sites. c 2013 by the American College of Nurse-Midwives. J Midwifery Womens Health 2013;58:683–689 Keywords: CenteringParenting, group health care, Centering Healthcare, postpartum, well baby, social support, dyads, interconception, empowerment, patient engagement
INTRODUCTION
OVERVIEW OF THE CENTERING MODEL
Experts in the field of child development recommend a family-centered approach to achieve the goals of comprehensive child health promotion, and clinicians know that the family system is the healthiest when the mother and infant both are thriving.1, 2 Child health is inextricably connected to the parents, and the CenteringParenting model is designed to address both the health of the mother and the well-baby care required to take on these goals. Previous research has demonstrated the efficacy of group care for pediatric visits, and numerous studies have focused on the CenteringPregnancy model of prenatal care. What sets CenteringParenting apart is that it provides group primary care for both the mother and the infant during the first postpartum year.3–6 Well-baby care is firmly established in the health care delivery system. Postpartum well-woman care is less structured, and this article therefore provides a particular focus on care of the new mother. Bringing care into the dyad focus emphasizes the importance of care during the postpartum year and can provide a potential mechanism for reimbursement. This article describes the mother-infant dyad care model and will be of special interest to women’s health providers who want to learn about how the model functions.
Address correspondence to Joanna Bloomfield, MPH, 8737 Colesville Rd, Suite 307, Silver Spring, MD 20910. E-mail: [email protected]
The Centering health care model integrates the 3 major components of care: health assessment, education, and support within the group environment, excluding the initial visit and medical issues requiring more privacy.7 Centering is designed to be a facilitative group, not a didactic class. As such, it shifts the group dominance from the clinician/cofacilitator to the group itself. All in the group are experts with the atmosphere encouraging true patient engagement in care. A recent issue of Health Affairs 8 focused on a variety of issues surrounding the need for more patient engagement in care, and the seminal document “Crossing the Quality Chasm” identified patient-centered care as one of the 6 major aims for health care reform.9 Attention to health literacy is encouraged as essential to true patient involvement in care.10 In fact, patient engagement is being termed the “blockbuster drug of the century.”11 Centering, with its focus on the needs of the patients in the group and the facilitated discussion that occurs at each session, is a true patient engagement model. Ideally, CenteringParenting is a continuity model that transitions seamlessly for women who have received care in CenteringPregnancy. Women in the Centering group who have given birth prior to the end of the group series often return to the group with their newborns and share in real time the joys and challenges of birth and new motherhood. Women still waiting for their own birth experience listen carefully to the birth stories, feel relieved to see that group members do survive the process of giving birth, and gain practical information watching a woman breastfeed her newborn in the group. Women who have been socialized to receiving care in
1526-9523/09/$36.00 doi:10.1111/jmwh.12132
c 2013 by the American College of Nurse-Midwives
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✦ CenteringParenting provides group primary care for both mother and infant during the first year of life and beyond. ✦ The model provides the opportunity for women’s health clinicians to remain involved with care during the postpartum
year and encourages dynamic team collaboration between pediatrics and women’s health. ✦ CenteringParenting is a continuity model that follows from CenteringPregnancy through the first year of life and that
provides opportunity for true patient engagement in care.
Table 1. 13 Essential Elements of Centering Health Care
1.
Health assessment occurs within the group space
2.
Participants are involved in self-care activities
3.
A facilitative leadership style is used
4.
The group is conducted in a circle
5.
Each session has an overall plan
6.
Attention is given to the core content, although emphasis may vary
7.
There is stability of group leadership
8.
Group conduct honors the contribution of each member
9.
The composition of the group is stable, not rigid
10.
Group size is optimal to promote the process
11.
Involvement of support people is optional
12.
Opportunity for socializing with the group is provided
13.
There is ongoing evaluation of outcomes
Source: Centering Healthcare Institute.
a Centering group move easily into the parenting group, doing their own self-assessments and that of their infants. CenteringParenting starts at approximately 2 weeks postpartum and continues at regular intervals throughout the first year of life. The model is scheduled for 9 visits, capitalizing on reimbursement available for 6 to 7 well-baby visits and offering the potential to be reimbursable for women’s health through postpartum visits, family planning counseling, and screenings for depression, among other critical prevention efforts. It is a true dyad model of care at which standard wellbaby assessment is done by the mother and the clinician, immunizations are administered, and women track their own health data with follow-up as needed. The model is defined by 13 Essential Elements that structure all groups (Table 1).12 THE POSTPARTUM YEAR Well-Woman Care
Access to quality preconception and interconception care can reduce the danger of maternal and infant mortality and pregnancy-related complications.13 According to Lu et al, the life course perspective hypothesizes that initial life exposures can affect prospective reproductive potential, and therefore birth outcomes are considered “the end product of not only nine months of pregnancy but the entire life course of the mother before the pregnancy.”14 The CenteringParenting model harnesses a life course perspective, incorporating the 684
input of group participants and health care professionals to enhance outcomes for maternal and child health. Traditional postpartum care focuses on follow-up from birth and contraceptive consultation, but adherence to this visit is low, particularly in high-risk communities.15 One of many reasons for this is that many women have obtained insurance just for their pregnancy and have little or no coverage for care after the postpartum visit. More than 40% of all births in the United States are covered by Medicaid; coverage comprises prenatal care throughout pregnancy as well as labor and birth and 60 days postpartum.16 Lu et al recommend that women receive at least 3 visits within the first 6 months postpartum, with additional visits for those with chronic needs or history of preterm birth.17 For most women, unless there is a need for ongoing contraceptive visits, there is little opportunity for the clinician to focus on psychosocial issues that may be present for the mother and her family.18 It is not uncommon for other health needs to develop during the perinatal period, and given that pregnancy and childbirth are significant life transitions, postpartum and interconception care should be critical opportunities for increased health care surveillance.19 Typical assessment and support needs include depression screening and follow-up, contraceptive initiation and continuance, breastfeeding support, diabetes and hypertension screening, monitoring return to prepregnancy weight or attaining weight goals, screening for family violence, and support for management of substance abuse. A focus on these issues during this postpartum period provides the best foundation for a later pregnancy and for general health and well-being of the mother and for her newborn infant.20 The CenteringParenting model offers ongoing opportunities for peer exchange, mutual support, and community building among mothers, partners, and their providers during a critical transition time and also is an efficient way to connect women with community resources. Group Well-Baby Care
Well-baby visits are designed to offer preventive health services to infants during the first year of life. Bright Futures, the guidelines of the American Academy of Pediatrics (AAP), outlines objectives for the care of children.21 Objectives for CenteringParenting well-child care follow the Bright Futures 21 goals and include: 1) establishing a standard of care for infants, children, and adolescents; 2) helping clinicians shift their thinking to a prevention-based, family-focused, and developmentally oriented direction; 3) fostering partnerships between families, clinicians, and communities; and 4) empowering families with the skills and knowledge to be Volume 58, No. 6, November/December 2013
active participants in their children’s healthy development. During traditional well-child visits, clinicians are charged with providing the Bright Futures recommendations for routine screening and immunizations as well as including opportunity for parent education/anticipatory guidance and reassurance, all within the short 15- to 20-minute time allotted for the visit. Because of such time constraints, patients and their clinicians frequently report dissatisfaction with typical well-child appointments and concern about adequate access, especially for vulnerable infants.22 A variety of interventions including group well-child care models have been developed to address these issues. In the early 1980s, Lucy Osborn, a pediatrician, published pioneering studies on group visits for well-child care that were designed to provide preventive health care to cohorts of pediatric patients in group settings. Her evaluation of wellchild group visits showed no significant difference between the intervention group and control group (individual care) related to illness-related contacts, visits to medical clinicians, or emergency room visits.23 This initial research on pediatric group care confirmed that a group approach was not only as efficient, but also comparable in terms of time spent with patients, utilization of health services, and patient satisfaction compared with traditional care.24 Dodds et al reported that clinicians offering group well-child visits were able to cover significantly more AAP-recommended information in their sessions than did clinicians in the control group, especially materials about developmental milestones, behavior, nutrition, and safety precautions. Group well-baby visits have also demonstrated increased distribution of health promotion information such as infant milestones and nutrition.25 The general impression may be that group well-baby care is for low-risk children. However, Taylor’s pivotal randomized controlled trial explored the impact of group care on high-risk children. The outcomes indicated that group well-child care is not only a feasible approach for infant care, but also for support of maternal-infant engagement and child development. Not only is group appropriate for high-risk infants, but it also provides a support system for parents caring for infants with more complex issues.26 More recently, an evaluation of a group care pilot modeled after CenteringParenting demonstrated that participants had comparable service consumption and immunization rates as those who opted for traditional individual care, as well as fewer emergency room visits and hospitalizations. The study revealed that nearly all patients engaging in the group wellbaby care model expressed high levels of satisfaction.27 CENTERINGPARENTING
In an ideal health system it could make sense to visualize care provided to the family as a whole because members make up a small community of interdependence. This could not be more clear than with the mother-infant that starts during pregnancy and then continues closely during the postpartum period and beyond. During the postpartum period the mother and infant are closely tied, and even if she has had previous children, this is a period of adjustment and redefinition. She is reframing her image of herself and needs time and support to do that well. Fouquier references the social relationships that develop Journal of Midwifery & Women’s Health r www.jmwh.org
in CenteringPregnancy groups as “an important attribute in the transition to the maternal role.”28 The group atmosphere allows the mother to share with a peer group and to receive support for difficult issues and assurance that she is not the only one struggling with adjustments.20 Dyad care fits easily with the family practice model but may be more challenging for specialists in women’s health and pediatrics. A credentialed family physician or nurse practitioner easily can generate 2 encounter forms for many of these dyad visits. A specialist in women’s health (a midwife, nurse practitioner, or obstetrician-gynecologist) can bill for sessions that focus specifically on women’s health or for referral visits such as contraception initiation/continuance or gynecologic concerns or annual examinations. If the women in the group are adolescents, a pediatrician may be able to bill for the entire dyad. Often the cofacilitator is a social worker who has special skills in depression screening and treatment and maternalinfant attachment, and they can bill for their services as well. The team approach to this model will provide optimal care and maximum reimbursement. Description of a CenteringParenting Group Session
When a new mother enters the CenteringParenting room, she sees other mothers with their infants, most of whom she is familiar with from her CenteringPregnancy prenatal group. There is music playing and a lot of discussion, especially around the table with healthy snacks. The medical assistant or nurse helps the woman check in and assists her to measure and record her own weight and blood pressure and then shows her the infant scale/measuring board, teaching her how to gather her infant’s data. The woman then meets with the clinician who has a private space off to the side; she has her own assessment with the clinician, who asks about her health, does a quick infant examination, and reviews immunizations, feeding, sleeping, and other topics. The cofacilitator for the group often is a social worker who asks the woman to do a short depression assessment and then directs her to the CenteringParenting notebook for the selfassessment sheet for that session. After assessments are completed, the group is brought together in a circle for a facilitated discussion that encourages women to exchange questions and ideas with each other and the facilitators. Often an interactive activity is used to prompt discussion of the self-assessment sheet for the day. The group sits in a circle on pillows on the floor with the infants in the middle. This provides an ideal visual for the clinician to observe the infants and mothers over the next hour for a better developmental assessment than could be possible in a short individual visit. Also, mothers are able to see how infants of the same age may have reached different developmental landmarks and may talk in the group about how to encourage crawling, early language development, and even socialization. Women also have an opportunity to share with each other the challenges and successes they are having with their role as new mothers. Some may share their nutrition and exercise goals, some have concerns about contraception, and others may be trying to balance work issues and breastfeeding. The combined wisdom of the women and additional suggestions from the facilitators make for a rich discussion that 685
Table 2. Mother and Infant Care Topics in the CenteringParenting Model
Women’s Assessment
Infant’s Assessment
Health
Health
Postpartum care
Height/weight/head
Weight management
circumference
Mental health/depression
Common conditions
screening
Figure 1. CenteringParenting Model: Group Dyad Care Source: Centering Healthcare Institute.
is much broader than what could happen one on one. One clinician described a Centering patient who was skeptical about the efficacy of contraceptives because of repeat pregnancies while using contraception. After learning about the positive experiences her peers had with long-term methods and then considering how contraception would help her to achieve the goals of finishing her studies, she made the decision to have an intrauterine device placed. Model Specifics
The model comprises 9 visits throughout the first postpartum year. Groups typically are filled by 6 to 7 mother-infant dyads, all of whom receive care in the group setting. During the group series, well-baby care is based on AAP-recommended periodic visits for preventive care, including developmental milestones and immunizations.29 Women receive family planning guidance to promote healthy pregnancy spacing following the American College of Obstetricians and Gynecologists guidelines.30 The schematic model in Figure 1 indicates the interaction of the mother-partner-child, surrounded by the family and more broadly by the care system and community.31 The care components are divided into 3 major areas of health, development, and safety, and all care is provided in the facilitated CenteringParenting group. Table 2 lists the major topics covered for the woman and infant during CenteringParenting. The model is cohort based, with all infants born within approximately one month of each other. This makes it easier to observe the age-specific spectrum of developmental changes and to provide a community of sharing for the mothers. CenteringParenting Clinical Care
The health component includes the physical and developmental assessment of the infant by the pediatric provider. The mother participates actively by weighing and measuring the infant and, recording the findings on a progress note. She also does her own health assessment by weighing herself, taking her blood pressure, and recording on her progress record. The clinician reviews with her any concerns and refers to a women’s health provider, as needed. If the clinician is cre686
Prevention
Family planning
Common illnesses
Nutrition and exercise
Nutrition
Breastfeeding
Breastfeeding
Oral health
Oral health
Immunizations
Immunizations
Development
Development
Motherhood
Milestones
Infant attachment
Behavior
Life balance
Prevention
Personal growth
Cognition and learning
Stress management
Motor skills
Safety
Safety
Safe sex
Car seat
Substance use
Childproofing
Relationships
Emergency response
Seat belts
Child care
Source: Centering Healthcare Institute.
dentialed for care of both mother and infant, it often will be possible to generate 2 encounter forms. A Centering notebook with educational material, self-assessment sheets, and progress records for both mother and infant provides the tools and some structure for the 9 sessions, but as with all Centering groups, the discussion is facilitated and focused on what is important to the group members rather than on a preset list of content. One of the Essential Elements of the Centering model is that 2 facilitators, including the care provider, are constant with the group. Because the major billing for the visits will be through the provision of well-baby care, the primary clinician will be credentialed in either family practice or pediatrics. In many instances a woman’s health provider, perhaps the person who cared for the woman during CenteringPregnancy, will also be available as needed to follow up on specific women’s health issues outside the scope of the pediatric provider. Conditions that develop during pregnancy, such as excessive weight gain and hypertension, need to be addressed and monitored during the postpartum period and into the first year.32, 33 Participants who have been in prenatal care through CenteringPregnancy come prepared for the group approach. Women are empowered to become more active by updating their own medical records as well as those of their infants, learning to interpret the growth charts used in pediatric visits, and reviewing results from lab work and other tests. Such transparency in the care setting has proven to be Volume 58, No. 6, November/December 2013
a powerful component of the Centering model.34 Groups offer a lively setting for skills building and sharing that is not seen in a traditional encounter in the clinic. The exchange of knowledge and concerns with other parents supports the normalization of their experiences with early parenting and can lead to social support development among group members. The group setting offers the chance for women and their partners to express the challenges they have confronted, ask questions about parenting, and swap information as each other’s best resource. Support for New Mothers
Beyond supporting healthy outcomes for infants, this model offers enhanced care for mothers. In addition to the standard 2- and 6-week postpartum visits, dyad care provides women the opportunity for care at 9 group sessions with continuous discussion focused on women’s health issues. For example, participants may discuss family size, stress reduction, return to work, and partner involvement. This method underscores the family-centered model established in prenatal groups, particularly the incorporation of health assessment, education, and support. Connections that form in prenatal groups reinforce peer education and confidence, and they ideally shift smoothly into CenteringParenting, where parents continue to expand their unified wisdom around taking care of themselves and their infants. Partners are welcomed as active members of the group and occasionally may replace the mothers at visits. EARLY EVALUATION OF THE MODEL: SUCCESSES AND CHALLENGES
In December 2012, Centering Healthcare Institute (CHI) conducted an assessment with 15 geographically diverse sites where the CenteringParenting model has been implemented. Through individual phone interviews, site staff from clinicians to community health workers were asked to: 1) explore successes and challenging aspects of the model, 2) consider the needs and wants of staff involved with the model, and 3) share feedback that would help CHI to better support sites with implementation and sustainability of the model. During the interviews, CHI gathered both quantitative and qualitative data from sites that included nurse practitioners, family practice physicians, pediatricians, family practice and pediatric residents, physician assistants, midwives, and obstetrician-gynecologists. Although not conducted as a formal qualitative research study, CHI staff identified several repetitive themes that emerged including importance of group support, patient satisfaction, sharing of content, logistics, and uptake challenges. Theme 1: Importance of Support Within Groups
Respondents felt best about contributing to the support for women in the groups. One clinician stated, “I feel good about building social support in our patient population and creating a forum where women feel supported; anytime a person can come to clinic and have a positive experience is good.” Another clinician stated that, “Women need a lot of support and attention, and they are learning to be moms. As clinicians we Journal of Midwifery & Women’s Health r www.jmwh.org
can undo myths and let them do their own research. I always say, ‘I wish I had Centering.’ We share a lot of information, and a woman can ask anything in this space without feeling judged.” Theme 2: Patient Satisfaction
Respondents described patient satisfaction and reported patients being interested in helping with recruitment. Patients and clinicians experience a different dynamic and learn from the varied directions of discussion. Clinic staff routinely reported retention rates between 75% and 95% in groups. One staff member stated that, “Retention is excellent; they all show up,” whereas another said, “Retention is harder when women return to work.” Theme 3: Patient Content Exchange
Learning from each other is of critical value in CenteringParenting. “I love the connections between the women and how they learn from each other through their common and shared experiences. When parents can see other kids at different levels, they can see development.” Another provider stated, “We learn things from them that you don’t learn in textbooks, and this contributes to our understanding of cultural beliefs and values.” Theme 4: CenteringParenting Logistics
One of the notable challenges among respondents was the general logistics of implementing CenteringParenting. Specific issues varied by clinic and included recruitment, clinician training, paperwork completion, managing larger groups, and scheduling. The model is designed to integrate the care provided to 2 separate patients in 2 different locations and usually by 2 different credentialed providers into a unified dyad. Besides the obvious issues that may arise from geographic separation of women’s health care and infant care, there is the need to set up new clinician lines of communication, to provide access to 2 separate charts, and to secure appropriate, safe space for care delivery. The need for a team approach that includes those with expertise in family dynamics including motherinfant attachment is critical. Clearly, this is a model that demands system redesign to sustain the change. Theme 5: Uptake of the CenteringParenting Model
Sites with more robust CenteringParenting models tended to have the family practice clinician leadership that could carry through from CenteringPregnancy prenatally and seamlessly transition into CenteringParenting postpartum. Approximately 70% of interviewed sites were recruiting the majority of participants from CenteringPregnancy. Clinics without CenteringPregnancy reported more challenges with recruitment and sustainability. As a clinician stated, “The biggest challenge was sustaining a model of care that was not an ‘opt-out’ model. This became a ‘specialty’ clinic that was sustained by a small group of people who invested considerable time and effort. Challenges included issues with registration; for example, often the infant was 687
registered for the visit, but the mother was not. Other barriers included staff unfamiliarity with the model; all staff and especially group facilitators need to be trained in the model. From these experiences we learned, as stated in the training, that an opt-out model of care for CenteringParenting has the best chance of success.” 34 In other words, CenteringParenting should be the standard model of care, and the default will be that patients will need to choose not to participate, rather than decide to enter it. SYSTEM REDESIGN
Changing systems can be difficult, and implementing and sustaining the Centering group care model involves participation of every service area as well as a fundamental change in how the facilitators provide care. Clinicians and staff have been trained to answer questions and work to efficiently move patients in and out of exam rooms. Implementation of the model includes both moving out of the privacy of the exam room into the more public group space as well as facilitating discussion rather than answering questions. The one-to-one relationship and often dependence on the clinician now are mediated by the increasing cohesion of the group and the natural efforts of the group to strategize solutions apart from the advice of the clinician. The clinicians and facilitators look for new markers of satisfaction for themselves as they see the patients increasingly rely on each other for support. The markers may include watching 2 previously isolated women walk out of the group together or listening to the group make plans to meet for an outing in the park or even watching a spontaneous collection of food, clothing, or money for a group member who is struggling. CenteringParenting has been most successful and sustainable in sites in which CenteringPregnancy has been implemented or is part of a broad implementation plan that offers professional support and management during the initial startup and the early adoption period. Training is focused on learning facilitation skills as well as specifics of dyad group care. A working steering committee, ideally with patients involved, is essential to initial implementation and long-term sustainability. And whenever there is substantial change to an organizational design, it is critical that evaluation be robust to help assure that there is better care and better health and that the cost estimate is favorable. The committee focuses on areas of greatest importance to the system, which often include appropriate space, scheduling and recruitment, staffing, billing, and training. The field of implementation science, “the scientific study of variables and conditions that impact changes at practice, organization, and systems levels,” outlines a 6step process that takes 2 to 4 years from the initial discussion to sustainable implementation.35 The site must be ready for change, and for a major change such as this to be sustainable, the major decision makers from the top down need to be involved. SUMMARY
This article describes the CenteringParenting model, a continuity model following from CenteringPregnancy through the 688
first year of life for anyone expecting a newborn and transitioning to parenthood. The model has demonstrated efficiency for participants and clinicians who facilitate care in the group setting. It also provides a unique model to potentially increase the delivery of women’s health care, which can lead to better outcomes for both mother and infant. It is an opportunity for midwives, nurse practitioners, and obstetriciangynecologists to have continuing contact with women during this intense time of physical and emotional transition for the new mother and to more formally contribute to the development of healthy families. It also is an opportunity for team building with those providing pediatric care and with community agencies dedicated to supporting new parents. CenteringParenting promotes a new model of dyad care throughout the first year of life and in doing so, brings the family into the center of the care environment. Although challenges are present during the initial implementation stages, with careful planning and training, these obstacles are surmountable. A 2006 article on CenteringPregnancy stated that “[r]elationships between and among health care providers and the women in the group are founded on the belief that each brings mutual knowledge and power to the relationship.”36 Although this concept theoretically is empowering to both the woman and her provider, it demands trust and a shift in the power differential that currently is present in many traditional visits. Centering is a model that supports the current efforts to get patients more engaged in their care. In a recent issue of Health Affairs devoted to the topic of patient engagement,8 Dentzer asserts that “[w]herever engagement takes place the emerging evidence is that patients who are actively involved in their health and health care achieve better health outcomes and have lower health costs than those who aren’t.”37 The results of true engagement are satisfying and rewarding for all participants and lead to our best efforts for better care, better health, and lower costs. AUTHORS
Joanna Bloomfield, MPH, is the Project Coordinator for Centering Healthcare Institute in the policy and innovation office in Silver Spring, Maryland. Sharon S. Rising, CNM, MSN, FACNM, is the founder and CEO of Centering Healthcare Institute and works in the policy and innovation office in Silver Spring, Maryland. CONFLICT OF INTEREST
The authors are both employed by Centering Healthcare Institute, which promotes the CenteringParenting model. ACKNOWLEDGMENTS
The authors gratefully acknowledge the contributions of Dr. Amy Gordon, MD, Dr. Pooja Mittal, DO, and Dr. Michelle Gallas, DO, in providing their insights from their work with CenteringParenting at their practice sites. We also thank our interviewees for sharing valuable feedback. Volume 58, No. 6, November/December 2013
REFERENCES 1.United States Department of Health and Human Services. 2011 Report to Congress: National strategy for quality improvement in healthcare. 2011:10-11. 2.Schor E. Rethinking well-child care. Pediatrics. 2004;114(1):210-216. 3.Klima C, Norr K, Vonderheid S, Handler A. Introduction of CenteringPregnancy in a public health clinic. J Midwifery Womens Health. 2009;54(1):27-34. 4.Ickovics J, Kershaw T, Westdahl C, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol. 2007;110(2):330-339. 5.Picklesimer A, Blackhurst D, Covington-Kolb S, Hale N, Billings D. The impact of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Obstet Gynecol. 2012;206(Suppl 1):S55-S56. 6.Rising S. Centering pregnancy: an interdisciplinary model of empowerment. J Nurse Midwifery. 1998;43(1):46-54. 7.Centering Healthcare Institute. Centering Healthcare Sites Web site. http://centeringhealthcare.org/pages/centering-model/modeloverview.php. Updated 2013. 8.Dentzer S, Metz D, eds. Patient engagement. Health Aff. 2013; 32(2, theme issue):197-440. 9.Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012. 10.Koh H, Brach C, Harris L, Parchman L. Proposed ‘health literate care model’ would constitute a systems approach to improving patients’ engagement in care. Health Aff. 2013;32(2):357-365. 11.Kish L. The blockbuster drug of the century: an engaged patient. http://www.hl7standards.com/blog/2012/08/28/drug-of-the-century. Published 2012. Updated 2013. Accessed February 2013. 12.Essential Elements. 13 Essential Elements of Centering Healthcare. https://www.centeringhealthcare.org/pages/centering-model/elements. php. Updated 2012. Accessed February 1, 2013. 13.Handler A, Rankin K, Peacock N, Townsell S, McGlynn A, Issel L. The implementation of interconception care in two community health settings: lessons learned. Am J Health Promot. 2013;27(Suppl 3):eS21eS31. 14.Lu M, Kotelchuck M, Hogan V, Jones L, Wright K, Halfon N. Closing the Black-White gap in birth outcomes: a life-course approach. Ethn Dis. 2010;20(1 Suppl):2-62. 15.Pies C, Parthasarathy P, Posner S. Integrating the life course perspective into a local maternal and child health program. Matern Child Health J. 2012;16(3):649-655. 16.Pregnant women. Medicaid.gov. Keeping America Healthy Website. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByPopulation/Pregnant-Women/Pregnant-Women.html. Updated 2012. Accessed February 1, 2013. 17.Lu M, Kotelchuck M, Culhane JF, Hobel CJ, Klerman LV, Thorp JM Jr. Preconception care between pregnancies: the content of internatal care. Matern Child Health J. 2006;10(5 Suppl):107-122. 18.Gjerdingen D, Crow S, McGovern P, Miner M, Center B. Postpartum depression screening at well-child visits: Validity of a 2-question screen and the PHQ-9. Ann Fam Med. 2009;7(1):63-70. 19.Salihu H, August E, Mbah A, et al. The impact of birth spacing on subsequent feto-infant outcomes among community enrollees of a federal healthy start project. J Community Health. 2012;37(1):137-142.
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20.Brink, S. The Fourth Trimester: Understanding, Protecting, and Nurturing an Infant Through the First Three Months. Berkeley, CA: University of California; 2012:174-175. 21.Bright futures recommendations for preventive pediatric health. In: Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Prevention and Health Promotion for Infants, Children, Adolescents and Their Families. 3rd ed. Elk Grove: American Academy of Pediatrics; 2008:289-383. 22.Jaber R, Braksmajer A, Trilling J. Group visits: a qualitative review of current research. J Am Board Fam Med. 2006;19(3):276-290. 23.Osborn L. Group well child care. Clin Perinatol. 1985;12(2):355-365. 24.Osborn, L. Group well-child care offers unique opportunities for patient education. Patient Educ Couns. 1989;14(3):227-234. 25.Dodds M, Nicholson L, Muse B, Osborn L. Group health supervision visits more effective than individual visits in delivering health care information. Pediatrics. 1993;91(3):668-670. 26.Taylor J, Davis R, Kemper K. A randomized controlled trial of group versus individual well child care for high-risk children: maternal-child interaction and developmental outcomes. Pediatrics. 1997;99(6):16. 27.Page C, Reid A, Hoagland E, Leonard S. WellBabies: Mothers’ perspectives on an innovative model of group well-child care. Fam Med. 2010;42(3):202-207. 28.Fouquier KF. State of the science: does the theory of maternal role attainment apply to African American motherhood? J Midwifery Womens Health. 2013;58:203-210. 29.American Academy of Pediatrics. Bright Futures Goals. 2012. www.brightfutures.aap.org/goals.html. Accessed January 10, 2013. 30.Committee opinion no. 505: understanding and using the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Obstet Gynecol. 2011;118(3):754-760. 31.Centering Healthcare Institute. CenteringParenting. 2013. https:// www.centeringhealthcare.org/pages/centering-model/parentingoverview.php. Accessed January 10, 2013. 32.Mielke RT, Kaiser D, Centuolo R. Interconception care for women with prior gestational diabetes mellitus. J Midwifery Womens Health. 2013;58(3):303-312. 33.Rothberg BE, Magriples U, Kershaw TS, Rising SS, Ickovics JR. Gestational weight gain and post-partum weight loss among young, low-income, ethnic minority women. Am J Obstet Gynecol. 2011;204(1):52.e1-52.e211. 34.Rising SS, Senterfitt C. Repairing health care: building relationships through groups. Creat Nurs. 2009;15(4):178-182. 35.Kotter JP. Leading Change. Boston, MA: Harvard Business Review Press; 2012. 36.Massey Z, Rising SS, Ickovics J. CenteringPregnancy group prenatal care: promoting relationship-centered care. J Obstet Gynecol Neonatal Nurs. 2006;35:286-294. 37.Dentzer S. Rx for the ‘blockbuster drug’ of patient engagement. Health Aff (Millwood). 2013;32(2):202.
Continuing education units (CEUs) for this article are offered as part of a CEU theme issue. To obtain CEUs online, please visit www.jmwhce.org. A CEU form that can be mailed or faxed is available in the print edition of the theme issue.
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Original Review
CenteringParenting: An Innovative Dyad Model for Group Mother-Infant Care
CEU
Joanna Bloomfield, MPH, Sharon Schindler Rising, CNM, MSN
CenteringParenting is a group model that brings a cohort of 6 to 7 mothers and infants together for care during the first year of life. During 9 group sessions the clinician provides well-baby care and also attends to the health, development, and safety issues of the mother. Ideally, CenteringParenting provides continuity of care for a cohort of women who have received care in CenteringPregnancy, group prenatal care that is 10 sessions throughout the entire pregnancy and that leads to community building, better health outcomes, and increased satisfaction with prenatal care. The postpartum year affects the entire family, but especially the mother, who is redefining herself and her own personal goals. Issues of weight/body image, breastfeeding, depression, contraception, and relationship issues all may surface. In traditional care, health resources for support and intervention are frequently lacking or unavailable. Women’s health clinicians also note the loss of contact with women they have followed during the prenatal period, often not seeing a woman again until she returns for another pregnancy. CenteringParenting recognizes that the health of the mother is tied to the health of the infant and that assessment and interventions are more appropriate and efficient when done in a dyad context. Facilitative leadership, rather than didactic education, encourages women to fully engage in their care, to raise issues of importance to them, and to discuss concerns within an atmosphere that allows for the surfacing of culturally appropriate values and beliefs. Implementing the model calls for system changes that are often significant. It also requires the building of a substantial team relationship among care providers. This overview describes the CenteringParenting mother-infant dyad care model with special focus on the mother and reviews the perspectives and experiences of staff from several practice sites. c 2013 by the American College of Nurse-Midwives. J Midwifery Womens Health 2013;58:683–689 Keywords: CenteringParenting, group health care, Centering Healthcare, postpartum, well baby, social support, dyads, interconception, empowerment, patient engagement
INTRODUCTION
OVERVIEW OF THE CENTERING MODEL
Experts in the field of child development recommend a family-centered approach to achieve the goals of comprehensive child health promotion, and clinicians know that the family system is the healthiest when the mother and infant both are thriving.1, 2 Child health is inextricably connected to the parents, and the CenteringParenting model is designed to address both the health of the mother and the well-baby care required to take on these goals. Previous research has demonstrated the efficacy of group care for pediatric visits, and numerous studies have focused on the CenteringPregnancy model of prenatal care. What sets CenteringParenting apart is that it provides group primary care for both the mother and the infant during the first postpartum year.3–6 Well-baby care is firmly established in the health care delivery system. Postpartum well-woman care is less structured, and this article therefore provides a particular focus on care of the new mother. Bringing care into the dyad focus emphasizes the importance of care during the postpartum year and can provide a potential mechanism for reimbursement. This article describes the mother-infant dyad care model and will be of special interest to women’s health providers who want to learn about how the model functions.
Address correspondence to Joanna Bloomfield, MPH, 8737 Colesville Rd, Suite 307, Silver Spring, MD 20910. E-mail: [email protected]
The Centering health care model integrates the 3 major components of care: health assessment, education, and support within the group environment, excluding the initial visit and medical issues requiring more privacy.7 Centering is designed to be a facilitative group, not a didactic class. As such, it shifts the group dominance from the clinician/cofacilitator to the group itself. All in the group are experts with the atmosphere encouraging true patient engagement in care. A recent issue of Health Affairs 8 focused on a variety of issues surrounding the need for more patient engagement in care, and the seminal document “Crossing the Quality Chasm” identified patient-centered care as one of the 6 major aims for health care reform.9 Attention to health literacy is encouraged as essential to true patient involvement in care.10 In fact, patient engagement is being termed the “blockbuster drug of the century.”11 Centering, with its focus on the needs of the patients in the group and the facilitated discussion that occurs at each session, is a true patient engagement model. Ideally, CenteringParenting is a continuity model that transitions seamlessly for women who have received care in CenteringPregnancy. Women in the Centering group who have given birth prior to the end of the group series often return to the group with their newborns and share in real time the joys and challenges of birth and new motherhood. Women still waiting for their own birth experience listen carefully to the birth stories, feel relieved to see that group members do survive the process of giving birth, and gain practical information watching a woman breastfeed her newborn in the group. Women who have been socialized to receiving care in
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c 2013 by the American College of Nurse-Midwives
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✦ CenteringParenting provides group primary care for both mother and infant during the first year of life and beyond. ✦ The model provides the opportunity for women’s health clinicians to remain involved with care during the postpartum
year and encourages dynamic team collaboration between pediatrics and women’s health. ✦ CenteringParenting is a continuity model that follows from CenteringPregnancy through the first year of life and that
provides opportunity for true patient engagement in care.
Table 1. 13 Essential Elements of Centering Health Care
1.
Health assessment occurs within the group space
2.
Participants are involved in self-care activities
3.
A facilitative leadership style is used
4.
The group is conducted in a circle
5.
Each session has an overall plan
6.
Attention is given to the core content, although emphasis may vary
7.
There is stability of group leadership
8.
Group conduct honors the contribution of each member
9.
The composition of the group is stable, not rigid
10.
Group size is optimal to promote the process
11.
Involvement of support people is optional
12.
Opportunity for socializing with the group is provided
13.
There is ongoing evaluation of outcomes
Source: Centering Healthcare Institute.
a Centering group move easily into the parenting group, doing their own self-assessments and that of their infants. CenteringParenting starts at approximately 2 weeks postpartum and continues at regular intervals throughout the first year of life. The model is scheduled for 9 visits, capitalizing on reimbursement available for 6 to 7 well-baby visits and offering the potential to be reimbursable for women’s health through postpartum visits, family planning counseling, and screenings for depression, among other critical prevention efforts. It is a true dyad model of care at which standard wellbaby assessment is done by the mother and the clinician, immunizations are administered, and women track their own health data with follow-up as needed. The model is defined by 13 Essential Elements that structure all groups (Table 1).12 THE POSTPARTUM YEAR Well-Woman Care
Access to quality preconception and interconception care can reduce the danger of maternal and infant mortality and pregnancy-related complications.13 According to Lu et al, the life course perspective hypothesizes that initial life exposures can affect prospective reproductive potential, and therefore birth outcomes are considered “the end product of not only nine months of pregnancy but the entire life course of the mother before the pregnancy.”14 The CenteringParenting model harnesses a life course perspective, incorporating the 684
input of group participants and health care professionals to enhance outcomes for maternal and child health. Traditional postpartum care focuses on follow-up from birth and contraceptive consultation, but adherence to this visit is low, particularly in high-risk communities.15 One of many reasons for this is that many women have obtained insurance just for their pregnancy and have little or no coverage for care after the postpartum visit. More than 40% of all births in the United States are covered by Medicaid; coverage comprises prenatal care throughout pregnancy as well as labor and birth and 60 days postpartum.16 Lu et al recommend that women receive at least 3 visits within the first 6 months postpartum, with additional visits for those with chronic needs or history of preterm birth.17 For most women, unless there is a need for ongoing contraceptive visits, there is little opportunity for the clinician to focus on psychosocial issues that may be present for the mother and her family.18 It is not uncommon for other health needs to develop during the perinatal period, and given that pregnancy and childbirth are significant life transitions, postpartum and interconception care should be critical opportunities for increased health care surveillance.19 Typical assessment and support needs include depression screening and follow-up, contraceptive initiation and continuance, breastfeeding support, diabetes and hypertension screening, monitoring return to prepregnancy weight or attaining weight goals, screening for family violence, and support for management of substance abuse. A focus on these issues during this postpartum period provides the best foundation for a later pregnancy and for general health and well-being of the mother and for her newborn infant.20 The CenteringParenting model offers ongoing opportunities for peer exchange, mutual support, and community building among mothers, partners, and their providers during a critical transition time and also is an efficient way to connect women with community resources. Group Well-Baby Care
Well-baby visits are designed to offer preventive health services to infants during the first year of life. Bright Futures, the guidelines of the American Academy of Pediatrics (AAP), outlines objectives for the care of children.21 Objectives for CenteringParenting well-child care follow the Bright Futures 21 goals and include: 1) establishing a standard of care for infants, children, and adolescents; 2) helping clinicians shift their thinking to a prevention-based, family-focused, and developmentally oriented direction; 3) fostering partnerships between families, clinicians, and communities; and 4) empowering families with the skills and knowledge to be Volume 58, No. 6, November/December 2013
active participants in their children’s healthy development. During traditional well-child visits, clinicians are charged with providing the Bright Futures recommendations for routine screening and immunizations as well as including opportunity for parent education/anticipatory guidance and reassurance, all within the short 15- to 20-minute time allotted for the visit. Because of such time constraints, patients and their clinicians frequently report dissatisfaction with typical well-child appointments and concern about adequate access, especially for vulnerable infants.22 A variety of interventions including group well-child care models have been developed to address these issues. In the early 1980s, Lucy Osborn, a pediatrician, published pioneering studies on group visits for well-child care that were designed to provide preventive health care to cohorts of pediatric patients in group settings. Her evaluation of wellchild group visits showed no significant difference between the intervention group and control group (individual care) related to illness-related contacts, visits to medical clinicians, or emergency room visits.23 This initial research on pediatric group care confirmed that a group approach was not only as efficient, but also comparable in terms of time spent with patients, utilization of health services, and patient satisfaction compared with traditional care.24 Dodds et al reported that clinicians offering group well-child visits were able to cover significantly more AAP-recommended information in their sessions than did clinicians in the control group, especially materials about developmental milestones, behavior, nutrition, and safety precautions. Group well-baby visits have also demonstrated increased distribution of health promotion information such as infant milestones and nutrition.25 The general impression may be that group well-baby care is for low-risk children. However, Taylor’s pivotal randomized controlled trial explored the impact of group care on high-risk children. The outcomes indicated that group well-child care is not only a feasible approach for infant care, but also for support of maternal-infant engagement and child development. Not only is group appropriate for high-risk infants, but it also provides a support system for parents caring for infants with more complex issues.26 More recently, an evaluation of a group care pilot modeled after CenteringParenting demonstrated that participants had comparable service consumption and immunization rates as those who opted for traditional individual care, as well as fewer emergency room visits and hospitalizations. The study revealed that nearly all patients engaging in the group wellbaby care model expressed high levels of satisfaction.27 CENTERINGPARENTING
In an ideal health system it could make sense to visualize care provided to the family as a whole because members make up a small community of interdependence. This could not be more clear than with the mother-infant that starts during pregnancy and then continues closely during the postpartum period and beyond. During the postpartum period the mother and infant are closely tied, and even if she has had previous children, this is a period of adjustment and redefinition. She is reframing her image of herself and needs time and support to do that well. Fouquier references the social relationships that develop Journal of Midwifery & Women’s Health r www.jmwh.org
in CenteringPregnancy groups as “an important attribute in the transition to the maternal role.”28 The group atmosphere allows the mother to share with a peer group and to receive support for difficult issues and assurance that she is not the only one struggling with adjustments.20 Dyad care fits easily with the family practice model but may be more challenging for specialists in women’s health and pediatrics. A credentialed family physician or nurse practitioner easily can generate 2 encounter forms for many of these dyad visits. A specialist in women’s health (a midwife, nurse practitioner, or obstetrician-gynecologist) can bill for sessions that focus specifically on women’s health or for referral visits such as contraception initiation/continuance or gynecologic concerns or annual examinations. If the women in the group are adolescents, a pediatrician may be able to bill for the entire dyad. Often the cofacilitator is a social worker who has special skills in depression screening and treatment and maternalinfant attachment, and they can bill for their services as well. The team approach to this model will provide optimal care and maximum reimbursement. Description of a CenteringParenting Group Session
When a new mother enters the CenteringParenting room, she sees other mothers with their infants, most of whom she is familiar with from her CenteringPregnancy prenatal group. There is music playing and a lot of discussion, especially around the table with healthy snacks. The medical assistant or nurse helps the woman check in and assists her to measure and record her own weight and blood pressure and then shows her the infant scale/measuring board, teaching her how to gather her infant’s data. The woman then meets with the clinician who has a private space off to the side; she has her own assessment with the clinician, who asks about her health, does a quick infant examination, and reviews immunizations, feeding, sleeping, and other topics. The cofacilitator for the group often is a social worker who asks the woman to do a short depression assessment and then directs her to the CenteringParenting notebook for the selfassessment sheet for that session. After assessments are completed, the group is brought together in a circle for a facilitated discussion that encourages women to exchange questions and ideas with each other and the facilitators. Often an interactive activity is used to prompt discussion of the self-assessment sheet for the day. The group sits in a circle on pillows on the floor with the infants in the middle. This provides an ideal visual for the clinician to observe the infants and mothers over the next hour for a better developmental assessment than could be possible in a short individual visit. Also, mothers are able to see how infants of the same age may have reached different developmental landmarks and may talk in the group about how to encourage crawling, early language development, and even socialization. Women also have an opportunity to share with each other the challenges and successes they are having with their role as new mothers. Some may share their nutrition and exercise goals, some have concerns about contraception, and others may be trying to balance work issues and breastfeeding. The combined wisdom of the women and additional suggestions from the facilitators make for a rich discussion that 685
Table 2. Mother and Infant Care Topics in the CenteringParenting Model
Women’s Assessment
Infant’s Assessment
Health
Health
Postpartum care
Height/weight/head
Weight management
circumference
Mental health/depression
Common conditions
screening
Figure 1. CenteringParenting Model: Group Dyad Care Source: Centering Healthcare Institute.
is much broader than what could happen one on one. One clinician described a Centering patient who was skeptical about the efficacy of contraceptives because of repeat pregnancies while using contraception. After learning about the positive experiences her peers had with long-term methods and then considering how contraception would help her to achieve the goals of finishing her studies, she made the decision to have an intrauterine device placed. Model Specifics
The model comprises 9 visits throughout the first postpartum year. Groups typically are filled by 6 to 7 mother-infant dyads, all of whom receive care in the group setting. During the group series, well-baby care is based on AAP-recommended periodic visits for preventive care, including developmental milestones and immunizations.29 Women receive family planning guidance to promote healthy pregnancy spacing following the American College of Obstetricians and Gynecologists guidelines.30 The schematic model in Figure 1 indicates the interaction of the mother-partner-child, surrounded by the family and more broadly by the care system and community.31 The care components are divided into 3 major areas of health, development, and safety, and all care is provided in the facilitated CenteringParenting group. Table 2 lists the major topics covered for the woman and infant during CenteringParenting. The model is cohort based, with all infants born within approximately one month of each other. This makes it easier to observe the age-specific spectrum of developmental changes and to provide a community of sharing for the mothers. CenteringParenting Clinical Care
The health component includes the physical and developmental assessment of the infant by the pediatric provider. The mother participates actively by weighing and measuring the infant and, recording the findings on a progress note. She also does her own health assessment by weighing herself, taking her blood pressure, and recording on her progress record. The clinician reviews with her any concerns and refers to a women’s health provider, as needed. If the clinician is cre686
Prevention
Family planning
Common illnesses
Nutrition and exercise
Nutrition
Breastfeeding
Breastfeeding
Oral health
Oral health
Immunizations
Immunizations
Development
Development
Motherhood
Milestones
Infant attachment
Behavior
Life balance
Prevention
Personal growth
Cognition and learning
Stress management
Motor skills
Safety
Safety
Safe sex
Car seat
Substance use
Childproofing
Relationships
Emergency response
Seat belts
Child care
Source: Centering Healthcare Institute.
dentialed for care of both mother and infant, it often will be possible to generate 2 encounter forms. A Centering notebook with educational material, self-assessment sheets, and progress records for both mother and infant provides the tools and some structure for the 9 sessions, but as with all Centering groups, the discussion is facilitated and focused on what is important to the group members rather than on a preset list of content. One of the Essential Elements of the Centering model is that 2 facilitators, including the care provider, are constant with the group. Because the major billing for the visits will be through the provision of well-baby care, the primary clinician will be credentialed in either family practice or pediatrics. In many instances a woman’s health provider, perhaps the person who cared for the woman during CenteringPregnancy, will also be available as needed to follow up on specific women’s health issues outside the scope of the pediatric provider. Conditions that develop during pregnancy, such as excessive weight gain and hypertension, need to be addressed and monitored during the postpartum period and into the first year.32, 33 Participants who have been in prenatal care through CenteringPregnancy come prepared for the group approach. Women are empowered to become more active by updating their own medical records as well as those of their infants, learning to interpret the growth charts used in pediatric visits, and reviewing results from lab work and other tests. Such transparency in the care setting has proven to be Volume 58, No. 6, November/December 2013
a powerful component of the Centering model.34 Groups offer a lively setting for skills building and sharing that is not seen in a traditional encounter in the clinic. The exchange of knowledge and concerns with other parents supports the normalization of their experiences with early parenting and can lead to social support development among group members. The group setting offers the chance for women and their partners to express the challenges they have confronted, ask questions about parenting, and swap information as each other’s best resource. Support for New Mothers
Beyond supporting healthy outcomes for infants, this model offers enhanced care for mothers. In addition to the standard 2- and 6-week postpartum visits, dyad care provides women the opportunity for care at 9 group sessions with continuous discussion focused on women’s health issues. For example, participants may discuss family size, stress reduction, return to work, and partner involvement. This method underscores the family-centered model established in prenatal groups, particularly the incorporation of health assessment, education, and support. Connections that form in prenatal groups reinforce peer education and confidence, and they ideally shift smoothly into CenteringParenting, where parents continue to expand their unified wisdom around taking care of themselves and their infants. Partners are welcomed as active members of the group and occasionally may replace the mothers at visits. EARLY EVALUATION OF THE MODEL: SUCCESSES AND CHALLENGES
In December 2012, Centering Healthcare Institute (CHI) conducted an assessment with 15 geographically diverse sites where the CenteringParenting model has been implemented. Through individual phone interviews, site staff from clinicians to community health workers were asked to: 1) explore successes and challenging aspects of the model, 2) consider the needs and wants of staff involved with the model, and 3) share feedback that would help CHI to better support sites with implementation and sustainability of the model. During the interviews, CHI gathered both quantitative and qualitative data from sites that included nurse practitioners, family practice physicians, pediatricians, family practice and pediatric residents, physician assistants, midwives, and obstetrician-gynecologists. Although not conducted as a formal qualitative research study, CHI staff identified several repetitive themes that emerged including importance of group support, patient satisfaction, sharing of content, logistics, and uptake challenges. Theme 1: Importance of Support Within Groups
Respondents felt best about contributing to the support for women in the groups. One clinician stated, “I feel good about building social support in our patient population and creating a forum where women feel supported; anytime a person can come to clinic and have a positive experience is good.” Another clinician stated that, “Women need a lot of support and attention, and they are learning to be moms. As clinicians we Journal of Midwifery & Women’s Health r www.jmwh.org
can undo myths and let them do their own research. I always say, ‘I wish I had Centering.’ We share a lot of information, and a woman can ask anything in this space without feeling judged.” Theme 2: Patient Satisfaction
Respondents described patient satisfaction and reported patients being interested in helping with recruitment. Patients and clinicians experience a different dynamic and learn from the varied directions of discussion. Clinic staff routinely reported retention rates between 75% and 95% in groups. One staff member stated that, “Retention is excellent; they all show up,” whereas another said, “Retention is harder when women return to work.” Theme 3: Patient Content Exchange
Learning from each other is of critical value in CenteringParenting. “I love the connections between the women and how they learn from each other through their common and shared experiences. When parents can see other kids at different levels, they can see development.” Another provider stated, “We learn things from them that you don’t learn in textbooks, and this contributes to our understanding of cultural beliefs and values.” Theme 4: CenteringParenting Logistics
One of the notable challenges among respondents was the general logistics of implementing CenteringParenting. Specific issues varied by clinic and included recruitment, clinician training, paperwork completion, managing larger groups, and scheduling. The model is designed to integrate the care provided to 2 separate patients in 2 different locations and usually by 2 different credentialed providers into a unified dyad. Besides the obvious issues that may arise from geographic separation of women’s health care and infant care, there is the need to set up new clinician lines of communication, to provide access to 2 separate charts, and to secure appropriate, safe space for care delivery. The need for a team approach that includes those with expertise in family dynamics including motherinfant attachment is critical. Clearly, this is a model that demands system redesign to sustain the change. Theme 5: Uptake of the CenteringParenting Model
Sites with more robust CenteringParenting models tended to have the family practice clinician leadership that could carry through from CenteringPregnancy prenatally and seamlessly transition into CenteringParenting postpartum. Approximately 70% of interviewed sites were recruiting the majority of participants from CenteringPregnancy. Clinics without CenteringPregnancy reported more challenges with recruitment and sustainability. As a clinician stated, “The biggest challenge was sustaining a model of care that was not an ‘opt-out’ model. This became a ‘specialty’ clinic that was sustained by a small group of people who invested considerable time and effort. Challenges included issues with registration; for example, often the infant was 687
registered for the visit, but the mother was not. Other barriers included staff unfamiliarity with the model; all staff and especially group facilitators need to be trained in the model. From these experiences we learned, as stated in the training, that an opt-out model of care for CenteringParenting has the best chance of success.” 34 In other words, CenteringParenting should be the standard model of care, and the default will be that patients will need to choose not to participate, rather than decide to enter it. SYSTEM REDESIGN
Changing systems can be difficult, and implementing and sustaining the Centering group care model involves participation of every service area as well as a fundamental change in how the facilitators provide care. Clinicians and staff have been trained to answer questions and work to efficiently move patients in and out of exam rooms. Implementation of the model includes both moving out of the privacy of the exam room into the more public group space as well as facilitating discussion rather than answering questions. The one-to-one relationship and often dependence on the clinician now are mediated by the increasing cohesion of the group and the natural efforts of the group to strategize solutions apart from the advice of the clinician. The clinicians and facilitators look for new markers of satisfaction for themselves as they see the patients increasingly rely on each other for support. The markers may include watching 2 previously isolated women walk out of the group together or listening to the group make plans to meet for an outing in the park or even watching a spontaneous collection of food, clothing, or money for a group member who is struggling. CenteringParenting has been most successful and sustainable in sites in which CenteringPregnancy has been implemented or is part of a broad implementation plan that offers professional support and management during the initial startup and the early adoption period. Training is focused on learning facilitation skills as well as specifics of dyad group care. A working steering committee, ideally with patients involved, is essential to initial implementation and long-term sustainability. And whenever there is substantial change to an organizational design, it is critical that evaluation be robust to help assure that there is better care and better health and that the cost estimate is favorable. The committee focuses on areas of greatest importance to the system, which often include appropriate space, scheduling and recruitment, staffing, billing, and training. The field of implementation science, “the scientific study of variables and conditions that impact changes at practice, organization, and systems levels,” outlines a 6step process that takes 2 to 4 years from the initial discussion to sustainable implementation.35 The site must be ready for change, and for a major change such as this to be sustainable, the major decision makers from the top down need to be involved. SUMMARY
This article describes the CenteringParenting model, a continuity model following from CenteringPregnancy through the 688
first year of life for anyone expecting a newborn and transitioning to parenthood. The model has demonstrated efficiency for participants and clinicians who facilitate care in the group setting. It also provides a unique model to potentially increase the delivery of women’s health care, which can lead to better outcomes for both mother and infant. It is an opportunity for midwives, nurse practitioners, and obstetriciangynecologists to have continuing contact with women during this intense time of physical and emotional transition for the new mother and to more formally contribute to the development of healthy families. It also is an opportunity for team building with those providing pediatric care and with community agencies dedicated to supporting new parents. CenteringParenting promotes a new model of dyad care throughout the first year of life and in doing so, brings the family into the center of the care environment. Although challenges are present during the initial implementation stages, with careful planning and training, these obstacles are surmountable. A 2006 article on CenteringPregnancy stated that “[r]elationships between and among health care providers and the women in the group are founded on the belief that each brings mutual knowledge and power to the relationship.”36 Although this concept theoretically is empowering to both the woman and her provider, it demands trust and a shift in the power differential that currently is present in many traditional visits. Centering is a model that supports the current efforts to get patients more engaged in their care. In a recent issue of Health Affairs devoted to the topic of patient engagement,8 Dentzer asserts that “[w]herever engagement takes place the emerging evidence is that patients who are actively involved in their health and health care achieve better health outcomes and have lower health costs than those who aren’t.”37 The results of true engagement are satisfying and rewarding for all participants and lead to our best efforts for better care, better health, and lower costs. AUTHORS
Joanna Bloomfield, MPH, is the Project Coordinator for Centering Healthcare Institute in the policy and innovation office in Silver Spring, Maryland. Sharon S. Rising, CNM, MSN, FACNM, is the founder and CEO of Centering Healthcare Institute and works in the policy and innovation office in Silver Spring, Maryland. CONFLICT OF INTEREST
The authors are both employed by Centering Healthcare Institute, which promotes the CenteringParenting model. ACKNOWLEDGMENTS
The authors gratefully acknowledge the contributions of Dr. Amy Gordon, MD, Dr. Pooja Mittal, DO, and Dr. Michelle Gallas, DO, in providing their insights from their work with CenteringParenting at their practice sites. We also thank our interviewees for sharing valuable feedback. Volume 58, No. 6, November/December 2013
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Journal of Midwifery & Women’s Health r www.jmwh.org
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