Teaching in a Patient-Centered Medical Home

Abstract

Teaching Lamaze International classes in a patient-centered medical home allows the childbirth educator the best environment for giving evidence-based information and empowering parents to give birth their way. Patient-centered medical home facilities and providers practice evidence-based care and adhere to the principles of family-centered maternity care. In patient-centered medical homes, women can expect to give birth using the Lamaze Healthy Birth Practices and to fully participate in their care with appropriate interventions and the right to informed consent and informed refusal.

Patient-centered medical homes (PCMHs) are the best-kept secret in medical care today. PCMHs practice according to the principles that Lamaze International educators, doulas, and family-centered providers long for in a medical system. In a PCMH, all providers are held accountable for evidence-based and family-centered care. Can you imagine what it would be like if all the providers you dealt with practiced according to these principles? I can tell you, because I work and teach in a PCMH—the University of North Carolina School of Medicine’s Department of Family Medicine.

Patient-centered medical homes are the best-kept secret in medical care today.

According to Sakala and Corry (2008), “Evidence-based maternity care uses the best available research on the safety and effectiveness of specific practices to help guide maternity care decisions and to facilitate optimal outcomes in mothers and newborns” (p. 3). Doulas and Lamaze educators find that they must remain current on the evidence so that their guidance of pregnant and parenting families is based on sound research. We often wonder if we are the only ones working so hard to keep up with the ever-changing research. Providers in a PCMH are held accountable for evidence-based practice; so they, too, must be current on best practices. They must have a compelling medical reason for the interventions they propose, the medications they prescribe, and the diagnostic testing they perform. Women who labor and give birth with PCMH providers will let labor start on its own, assume their preferred positions that are comfortable during labor, eat and drink at will during labor, use only the medically indicated interventions they agree to, have continuous emotional and physical support, and give birth in a position comfortable for them (usually upright). In addition, they will not be separated from their newborns, allowing them time and opportunity to establish breastfeeding.

The quad marker screen is a blood test that provides a woman and her health-care provider with useful information about her pregnancy. Substances in the mother’s blood sample are measured to screen for problems in the development of the fetus’s brain, spinal cord, and other neural tissues of the central nervous system (neural tube), as well as for genetic disorders such as Down syndrome.

Family-centered care ensures that the provider’s plans of care are discussed with expectant mothers, and if the mothers decline, there is no blaming, threatening, or pressure. In many current practices, if an expectant mother is older than 35 years old, she is told that she must have the quad marker screen, or her provider will no longer care for her. In a PCMH, the expectant mother is informed about the risks and benefits of such screenings and given an opportunity to ask questions and have them answered fully. If she declines the screening and the provider feels strongly that she should be screened, the provider provides more information about why the procedure is being so strongly recommended. If the expectant mother declines again, it is simply noted in her chart. Even in case conferences at the PCMH where I work, I have yet to hear anyone get angry over an expectant mother’s decision. The discussion focuses on alternative ways to keep the mother and baby safe and to get the information that is needed.

Although early work on the medical home concept was conducted by pediatricians and focused on the care of children with special needs, the concepts embedded in the PCMH were developed by a collaboration of the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association. The joint principles, created and supported by all four of these organizations, define the following key characteristics of the PCMH that relate to maternal–child care.

PERSONAL PHYSICIAN

For more information about Centering Healthcare Institute’s model of care, visit their Web site at http://www.centeringhealthcare.org/index.php.

In a PCMH facility, each client has an ongoing relationship with a personal physician trained to provide continuous and comprehensive care. At the PCMH where I work, the clinician may be a resident, an attending faculty member, or a nurse practitioner. Each clinician is responsible for providing for all the client’s health-care needs or for appropriately arranging care with other qualified professionals. Provision of care may involve radiology, pharmacology, nutrition, social work, financial counselors, maternal–fetal medicine, doulas, lactation consultants, or obstetricians. An expectant mother is assigned to a team of three residents, according to her due date. One of the residents is accountable for the mother’s healthy pregnancy and serves as her primary care physician; the mother will meet the other members of her team in the last visits before the birth. If the expectant mother chooses group prenatal care, based on the Centering Healthcare Institute’s model of care, her team will rotate through the group visits, with the attending physician or midwife serving as her constant provider. The expectant mother is still assigned a primary care provider who oversees each aspect of her care. In family medicine, this same clinician can take care of the mother’s newborn and the other members of her family.

QUALITY AND SAFETY: THE HALLMARK OF PATIENT-CENTERED MEDICAL HOMES

In maternity care, safety may oftentimes be achieved more by what we do not do than by the extensive use of routine interventions. Research confirms that women can eat and drink during labor, move around freely, assume upright positions for birth, and improve outcomes with less medicalized, interventionist care. In a PCMH, the clinician must have a justified medical reason, based on reliable evidence, for the use of interventions. Expectant mothers who want a trial of labor after cesarean surgery are assessed and given the appropriate care to help them achieve a vaginal birth after a cesarean.

In maternity care, safety may oftentimes be achieved more by what we do not do than by the extensive use of routine interventions.

In a PCMH, systems are put into place so that medical errors are minimized. Electronic charting has an alert system so that medications cannot be prescribed if the drug interaction check discovers a problem between the drug and the client’s allergies. Prescriptions are electronically produced and can be electronically sent to many pharmacies. The electronic medical records alert clinicians when immunizations are due or when medications are outdated. The systems are regulated and updated to ensure that clients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner.

EMPOWERING WOMEN AND THEIR FAMILIES

Shared decision making is the key to gaining trust, improving compliance, and ultimately improving outcomes. It facilitates learning in both the client and the clinician. An expectant mother may wish to avoid any type of medical induction until 42 weeks. In a PCMH, clinicians counsel their clients and collectively work toward a birth plan that both parties can feel safe with. Clients in group prenatal care take their own charts and record date, gestational age, fetal movement, weight, and blood pressure.

Shared decision making is the key to gaining trust, improving compliance, and ultimately improving outcomes.

At the PCMH where I work, I once asked a returning client how she became so smart about birth choices. She replied that she had participated in group prenatal care and felt much more educated and empowered about her birth. Clients have the phone number of the pager for the Maternal Child Health Program at my PCMH where their questions and fears can be addressed when the Department of Family Medicine is closed. Clients will reach one of the residents on the labor and delivery unit rotation and can call nights, holidays, and weekends. This service also adds to the safety of care.

THE EXPERIENCE OF TEACHING IN A PATIENT-CENTERED MEDICAL HOME

The only comparison I have to teaching Lamaze Healthy Birth classes in a PCMH is when I have taught homebirth parents in my home. In my classes at home, I did not feel the need to role-play discussions between clinician and parents for the purpose of having a say in the plan of care. I did not have to warn parents about unnecessary interventions, and I could help them see how interventions can be beneficial when used only as needed. At the PCMH where I work, I can now empower parents instead of trying to protect them, and I can put support behind my birth education. We have a lactation consultant who meets with each expectant mother in the final month of her pregnancy for breastfeeding preparation, and then calls each mother around 2 days after her discharge from the hospital. The lactation consultant is also available by phone or in person to answer new mothers’ breastfeeding questions.

To view videos produced on each of the six Lamaze Healthy Birth Practices and to read about the evidence-based research that supports these practices, visit the Lamaze Web site (www.lamaze.org).

PCMHs walk the walk and talk the talk. The National Committee for Quality Assurance (NCQA) has high standards for recognizing a facility as a PCMH (NCQA, 2011). According to a recent graph posted on the NCQA homepage (http://www.ncqa.org), from December 2008 to March 2011, 1,810 facilities throughout the United States have been recognized at varying levels as PCMHs. Within the PCMH, clinicians provide continuous, evidence-based, patient-centered, and culturally appropriate care.

We are well aware that a woman’s birth experience depends on the character and quality of the facility and clinician she chooses. It is time for Lamaze educators, doulas, lactation consultants, and birth networks to examine the quality of care that mothers and their families receive in a PCMH and refer them to this exemplary model of care.

Biography

BARBARA A. HOTELLING is the perinatal nurse coordinator for the Maternal and Child Health Program and a nurse practitioner in the Department of Family Medicine at the University of North Carolina School of Medicine in Chapel Hill. She has served as the president of Lamaze International and of DONA International, as well as chair of the Coalition for Improving Maternity Services.