Professions and Public Health Subcommittee Meeting Packet, February 10, 2021
Summary
A meeting packet for the Professions & Public Health Subcommittee, Wednesday, February 10, 2021, in Webster Hall, with Will Robinson as Chair and Chris Sprowls as Speaker. The meeting notice lists a Workshop on Florida Pregnancy-Associated Mortality with presenters from the Florida Department of Health, the Florida Perinatal Quality Collaborative and the Florida Association of Healthy Start Coalitions, Inc. The packet includes a presentation by Deborah Burch on the Florida Pregnancy-Associated Mortality Review (PAMR), with definitions and process steps. It states that in 2018 the leading pregnancy-related causes of death were Cardiomyopathy (19.4%) and Hemorrhage (16.7%). It also includes a biography of William Sappenfield and a Healthy Start presentation.
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“Professions and Public Health Subcommittee Meeting Packet, February 10, 2021.”
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Professions and Public Health
Subcommittee
Wednesday, February 10, 2021
10:00 AM - 11:30 AM
Webster Hall (212 Knott)
Meeting Packet
Chris Sprowls Will Robinson
Speaker Chair
Committee Meeting Notice
HOUSE OF REPRESENTATIVES
Professions & Public Health Subcommittee
Start Date and Time: Wednesday, February 10, 2021 10:00 am
End Date and Time: Wednesday, February 10, 2021 11:30 am
Location: Webster Hall (212 Knott)
Duration: 1.50 hrs
Workshop on Florida Pregnancy-Associated Mortality
- Deborah Burch, DNP, RN, Program Administrator, Maternal and Child Health, Florida Department of
Health
- William Sappenfield, MD, MPH, CPH, Director, Florida Perinatal Quality Collaborative, University of
South Florida
- Cathy Timuta, Chief Executive Officer, Florida Association of Healthy Start Coalitions, Inc.
This meeting will be live-streamed on https://thefloridachannel.org/. As no filed bills or draft legislation will
be considered at this meeting, public testimony will not be solicited and seating will be limited to the
Members, invited presenters, and the press. As always, you may contact any Representative prior to the
start of the meeting. Contact information may be found at
https://www.myfloridahouse.gov/Representatives.
NOTICE FINALIZED on 02/03/2021 4:09PM by Osborne.Erin
02/03/2021 04:09:52PM Leagis ® Page 1 of 1
Deborah Burch, DOH
Department of Health
The Florida Pregnancy-Associated
Mortality Review (PAMR)
The Florida Pregnancy-Associated Mortality
Review (PAMR)
Deborah Burch, DNP, RN
Maternal and Child Health (MCH)
Program Administrator
February 10, 2021
2
Definitions
Maternal Mortality – The death of a woman while pregnant or within 42 days of the
pregnancy ending, irrespective of the duration and site of the pregnancy, from any
cause related to or aggravated by the pregnancy or its management but not from
accidental or incidental causes (World Health Organization).
Pregnancy-Associated Death (PAD) – A death of a woman from any cause, while
she is pregnant or within one year of termination of pregnancy, regardless of the
duration and site of pregnancy (Centers for Disease Control and Prevention [CDC]).
Pregnancy-Related Death (PRD) – A pregnancy-associated death directly
attributed to pregnancy and/or childbirth (CDC).
3
Definitions, Continued
Maternal Mortality Rate (MMR) – The number of maternal deaths within
42 days of the ending of a pregnancy per 100,000 live births, from a
cause related to the pregnancy (National Center for Health Statistics).
Pregnancy-Associated Mortality Ratio (PAR) – The number of
pregnancy-associated deaths per 100,000 live births (CDC).
Pregnancy-Related Mortality Ratio (PRMR) – The number of
pregnancy-related deaths per 100,000 live births (CDC).
4
Methods of Maternal Mortality Review
5
Florida PAMR
Initiated:
• By the Florida Department of Health in 1996 to improve surveillance and
analysis of pregnancy-related deaths in Florida.
o Funded through Title V (MCH) Block Grant and the American
College of Obstetricians and Gynecologists (ACOG) District XII
o Florida statutory authority: 395.3025, 405.01, 766.101
Purpose:
• To discover gaps in care, identify systemic service delivery issues and
make recommendations to facilitate improvements in the overall systems
of care.
6
Florida PAMR Process
1. Identify all pregnancy-associated deaths.
• Death certificate with a cause of death in the category of
Pregnancy, Childbirth and Puerperium
• Universal Prenatal Risk Screen
• Linked infant birth certificate or fetal death certificate
• Pregnancy check-box on death certificate
2. Perform thorough record abstraction (using a variety of
record sources).
7
Florida PAMR Process, Continued
3. Perform a multidisciplinary committee review.
• Determine the underlying cause of death and preventability.
• Identify contributing factors.
• Recommend improvements to care.
4. Translate findings and recommendations into quality
improvement strategies.
8
Florida PAMR Process, Continued
5. Disseminate Information.
• Reports (annual and multi-year)
• Briefs focused on specific causes of death
• Urgent Maternal Mortality Messages (UMMM)
• Presentations at national, state and local forums
• Publications in peer reviewed journals
9
Florida PAMR Data Findings
Background and Significance
• In Florida, from 2008-2018:
o An average of 40 women died per year due to complications
of pregnancy = 1 woman dying every 9 days.
• 69% of the pregnancy related deaths in 2018 were determined to
be preventable.
11
Pregnancy-Associated Mortality Ratios (PAR) and
Pregnancy-Related Mortality Ratios (PRMR), Florida, 2008–2018
90
80
Ratio per 100,000 Live Births
70
60
50
40
30
20
10
0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
PAR PRMR
12
Pregnancy-Related Mortality Ratios
by Race/Ethnicity, Florida, 2008–2018
70
Ratio per 100,000 Live Births
60
50
40
30
20
10
0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Total PRMR Non-Hispanic White Non-Hispanic Black Hispanic
13
Comparison of Two 5-Year Periods:
Race and Ethnicity
14
Comparison of Two 5-Year Periods:
Cause of Death
Overall Pregnancy-Related Mortality Ratio
Florida, 2009–2018
Hemorrhage
Cardiomyopathy
Infection
Thrombotic embolism
Cardiovascular
Other
Hypertensive disorder
Cerebrovascular accident
Unknown
Amniotic fluid embolism
Anesthesia
Depression
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
p<0.01
2014–18 2009–13
15
Florida PAMR 2018 Findings
The leading pregnancy-related causes of death in 2018 were:
• Cardiomyopathy (19.4%)
• Hemorrhage (16.7%)
• Thrombotic Embolism (11.1%)
• Infection (11.1%)
• Cardiovascular Diseases (8.3%)
• Hypertensive Disorder (8.3%)
Most PRDs (80.6%) occurred during the postpartum period. Of this percentage:
• 25.0% occurred prior to hospital discharge
• 55.6% occurred after hospital discharge
16
Florida PAMR: Recommendations to Actions
Key Partnerships:
• American College of Obstetricians and Gynecologists (ACOG)
District XII
• Florida Perinatal Quality Collaborative (FPQC)
17
Florida PAMR: Recommendations to
Actions, Continued
Past FPQC Quality Improvement Initiatives:
• Obstetric Hemorrhage Initiative (OHI)
• Hypertension in Pregnancy (HIP) Initiative
• Access Postpartum Long-Acting Reversible Contraceptive
(LARC) Initiative
18
Florida PAMR: Recommendations to
Actions, Continued
Current FPQC Quality Improvement Initiatives:
• Promoting Vaginal Deliveries (PROVIDE) Initiative
• Maternal Opioid Recovery Effort (MORE) Initiative
19
Florida PAMR: Recommendations to
Actions, Continued
Urgent Maternal Mortality
Messages:
• Hemorrhage and Placental
Disorders
• Peripartum
Cardiomyopathy
• Maternal Early Warning
System (MEWS)
• Opioid Use During
Pregnancy
20
PAMR Successes
• A significant decrease in the Black-White racial disparity gap from 8.7
to 2.5.
• Overall reduction in PRMR: 21.8 down to 15.5.
• Reduction in PRMR in Black women 46.6 down to 29.4.
• Reduction in PRMR in Hispanic women 12.8 down to 7.4.
• Reduction in PRMR in White women 15.8 down to 14.5.
21
PAMR Successes
• FL PAMR has served as a model program for the country
• PAMR members are content experts (sharing tools, resources
and insight) for the CDCs national initiative Enhancing Reviews
and Surveillance to Eliminate Maternal Mortality (ERASE MM)
• FL PAMR was one of the first MMRCs to adopt the CDC hosted
Maternal Mortality Review Information Application (MMRIA)
national database.
22
PAMR Successes
• Consistent and standardized process over 25 years.
• PAMR members share findings and promote change through
conferences, newsletters, Grand Rounds, Urgent Maternal
Mortality Messages, and scholarly publications.
• Florida Association of Healthy Start Coalitions and one Federal
Healthy Start project have implemented PAMR
recommendations into their guidelines for care.
23
Florida PAMR
For more information, visit the PAMR website
http://www.floridahealth.gov/statistics-and-data/PAMR/index.html
For questions, please contact:
Deborah Burch DNP, RN
Deborah.Burch@flhealth.gov
24
Dr. William Sappenfield,
USF
William Sappenfield, MD, MPH, CPH
Professor, Director of Chiles Center, University of South Florida
William M. Sappenfield, MD, MPH is professor and chair of the Department of Community and Family
Health and Director of the Lawton and Rhea Chiles Center for Healthy Mothers and Babies at the College
of Public Health, University of South Florida. He just started this new career opportunity at USF to teach
and develop new professionals in December 2011. His vision is to make the Chiles Center one of the
leading national centers in maternal and child health practice and research.
As both a pediatrician and an epidemiologist, Dr. Bill Sappenfield has more than 27 years of experience
in epidemiological teaching, research and practice in maternal and child health at a local, state and
national level. Dr. Sappenfield received his medical degree from Louisiana State University Health
Sciences Center in New Orleans in 1980 and his masters of public health with a concentration on
epidemiology from Harvard University in 1984. He completed his pediatric residency training at
Vanderbilt University Medical Center in 1983 and his preventive medicine residency training at the
Centers for Disease Control and Prevention (CDC) in 1987. He also received applied epidemiology
training through CDC’s Epidemic Intelligence Service (EIS) program from 1984 to 1986.
As a nationally recognized leader in the field of maternal and child health epidemiology, Dr. Sappenfield
spent the first 21 years of his career as a CDC epidemiologist working with state and local public health
agencies to enhance their capacity to use epidemiology to improve the health of the women and
children. This included being assigned to state public health agencies in Massachusetts, Mississippi and
South Carolina. He was also assigned to work at CityMatCH—a national public health organization
working with MCH Leaders in urban public health agencies, at the University of Nebraska Medical
Center. He completed his CDC career serving four years as Team Leader of their MCH Epidemiology
Program directly responsible for the national MCH EPI effort including mentoring senior MCH
epidemiologists assigned around the nation.
For the next six years, Dr. Sappenfield served at the Florida Department of Health as the State MCH
Epidemiologist and as Unit Director for the MCH Practice and Analysis Unit. His responsibilities include
leading the Department’s MCH epidemiology and evaluation efforts including directing a unit of six
epidemiologists; working with MCH programs in Family Health and other divisions; collaborating with
state agencies, organizations, and universities; and assisting County Health Departments and community
partners.
Dr. Sappenfield’s major contributions to the MCH field include early efforts to develop community-
based fetal and infant mortality reviews, to adapt the perinatal periods of risk approach to assess infant
mortality in U.S. communities, to propose state preconception health indicators and to shape best
practices in applied MCH epidemiology. His current research projects include: maternal and infant
mortality, chronic diseases during pregnancy, assistive reproductive technology, unintended pregnancy
and contraceptive use, non-medically indicated deliveries prior to 39 weeks, population-based perinatal
quality improvement efforts, access to childhood preventive dental care, and use of data file linkages in
maternal and child health. He continues to mentor both young and senior MCH epidemiologist in public
health practice around the nation.
Dr. Sappenfield has received several national and state awards. In 2003, he received the National MCH
Epidemiology Award for Outstanding Leadership sponsored by 16 national health organizations.
Florida Perinatal Quality Collaborative (FPQC):
Improving the Health & Health Care of
Florida’s Mothers & Babies
William M. Sappenfield, MD, MPH, CPH
Professor & Director
Florida Perinatal Quality Collaborative
Vision
“All of Florida’s mothers and infants will have the best health
outcomes possible through receiving high quality evidence-based
perinatal care.”
Values
• Data-Driven
• Voluntary
• Population-Based
• Evidence-Based
• Value Added
2 2
FPQC Partners & Funders
3 3
Quality Improvement
The Framework for QI
What are we trying
to accomplish?
How will we know Plan Do
that a change is an
improvement?
Act Study
What change can we
make that will result
in improvement?
Associates in Process Improvement: Model for Improvement
4 4
“A Quality Collaborative is like a Car…”
5
FPQC Initiative Resources
Technical Project-wide in- Educational
Monthly and
person sessions,
Assistance collaboration videos, and
Quarterly QI
Data Reports
meetings resources
from FPQC
staff, state
Clinical Advisors,
and National Custom, Personalized
Monthly
Experts Consultations & Grand
e-mail blasts
Rounds Education
Monthly
Collaboration
Calls with
Online Tool Box
hospitals Algorithms, Sample protocols, Maternal education
state-wide tools, Slide sets, etc.
6
Multiple Pressure Points to Improve Quality
Government
Reporting
Consumer Professional
Ratings Organizations
7
Pregnancy-Related Mortality Ratios by Underlying Cause
Florida, 2009-2018
Hemorrhage
Infection
Hypertensive disorder
Other
Cardiovascular
Thrombotic embolism
Cardiomyopathy 2014-18
Amniotic fluid embolism 2009-13
Unknown
Cerebrovascular accident
Anesthesia
Depression
0.0 1.0 2.0 3.0 4.0 5.0
p<0.01
Deaths per 100,000 Live Births
8
Hypertension in Pregnancy (HIP)
Change Package Elements
Readiness
• Diagnostic criteria, monitoring and treatment
• Timely triage from ER and outpatient
• Rapid access to medications
Recognition
• Assessment protocols
• Response to early warning criteria
• Educating women on signs and symptoms
Response
• Protocols for management/treatment
• Support plans for patients, families & staff
• Simulations
• Debriefs
9
Percent of HIP Hospitals that Treated Women
with Persistent New-Onset Severe HTN in 1 hour
100%
7%
75 to 100% of women
treated within 1 hour
Percent of Hospitals
80%
50% 63% 1 to 74% of women
60% treated within 1 hour
No women treated
40% within 1 hour
20% 43% 38%
0% 0%
Baseline End
10 10
Percent of HIP Hospitals Where Women
Received Discharge Education Material
100%
90% 75 to 100% of women received
26% discharge education material
80%
Percent of Hospitals
1 to 74% of women received
70% discharge education material
60% 27% No women received discharge
50%
92% education material
40%
30%
20% 46%
10%
0%
8%
Baseline End
11 11
Florida Pregnancy-Related Mortality Ratio
Due to Hypertension, 2009-2018
Overall
p<0.001
2014-18
NH White 2009-13
NH Black
Hispanic
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0
Deaths per 100,000 Live Births
12
FPQC Initiatives
PROVIDE 1.0 PROVIDE 2.0
Maternal
Health
Access LARC MORE
Infant
NAS—Neonatal Abstinence
Health
Perinatal QI Indicators
Data
Birth Certificate Birth Certificate
Initiative Registration Workshops
2018 2019 2020 2021
13
FPQC Hospital Participation—2020
113 Florida
Maternity Infant Health Maternal Health
Hospitals Initiatives: 33 Initiatives: 78
74 Florida
Level II & III QI Indicators:
NICUs 53
FPQC Annual 2019
Conference: 42
MORE: Maternal Opioid
Recovery Effort
More:
Attention
Support
Services
Follow up
Compassion
15 15
23 MORE
Hospitals
(35% of Births)
16
MORE Patient Education Material
17 17
MORE 4-Part Video Series
From Judgment to Healing:
The Impact of Stigma
Getting Real: Taking the First
Steps Toward Recovery
Screening, Brief Intervention,
and Referral to Treatment
Mothers & Babies to
Services: Plans of Safe Care
18 18
MORE Folders &
Huddles
MORE folders include:
Patient care check list
Provider and patient education
Team huddles at admission
to coordinate care
Pilot in 4 hospitals
19
Putting the Community
Pieces Together for
Opioid Exposed Mothers
Contracting with Florida Healthy Start for community
resource directories and consultation
Statewide ad hoc committee on Plans of Safe Care:
Common messages & reporting system
Action plans for maternity units to be able to
distribute Naloxone free at discharge
Statewide ad hoc committee to address community barriers
to mothers receiving medication-assisted treatment
20
Monthly Coaching Calls
• Small hospital groups
• Physician & nursing leads
• Select one brief
discussion topic
• Celebrate successes
• Discuss challenges
• Share 30-60-90 day plans
February 9, 2021 21
Maternal Screening in Hospital
100
90
80
Percentage
70 Substance Use Dis.
Mental Health
60 Int. Partner Violence
Infectious Diseases
50
Q1 Q2 Q3 Q4
22
Behavioral Health /
Medication-Assisted Treatment
Not Stated
Pregnancy
Admission
Postpartum
Unknown
23
Comprehensive Discharge Planning
Q1 Q2 Q3 Q4
Narcan education 21% 1% 5% 9%
Social work consultation 96% 94% 95% 96%
Contraceptive plan 56% 58% 52% 68%
OB postpartum visit 16% 23% 21% 13%
Pediatric consult 72% 78% 72% 92%
Behavioral/MAT referral 46% 48% 31% 28%
Healthy Start referral 85% 77% 75% 80%
24
Promoting Primary Vaginal Deliveries
(PROVIDE 2.0)
Promoting Safe Vaginal Birth &
Reducing Unnecessary Low Risk Cesareans (NTSV)
25
2019 Low-Risk Nulliparous Term Singleton Vertex -
NTSV Cesarean Rate, FL birthing hospitals
70%
Range: 10.8%-57.9%
60%
Mean: 30.4%
50% Median: 28.6% Joint Commission
40% 2030 National Reporting > 30.0%
Target = 23.6%
30%
20%
10%
0% 1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
53
55
57
59
61
63
65
67
69
71
73
75
77
79
81
83
85
87
89
91
93
95
97
99
101
103
105
107
109
111
113
26
74 PROVIDE
Hospitals
(80% of Births)
27
NON-PROVIDE Baseline
PROVIDE Baseline
Enrollment
28
NTSV Cesarean Rates by Delivery Attendant
29
Labor Support Skills to Promote Vaginal Deliveries
Online videos to support hospital training
30 30
Quality Improvement
The Framework for QI
What are we trying
to accomplish?
How will we know Plan Do
that a change is an
improvement?
Act Study
What change can we
make that will result
in improvement?
Associates in Process Improvement: Model for Improvement
31 31
Questions?
wsappenfield@usf.edu
fpqc@usf.edu
www.fpqc.org “To improve the health and
health care of Florida’s
mothers and babies”
Cathy Timuta,
Florida Healthy Start
Bio: Cathy Timuta, MBA
(rev. 2-1-21)
Cathy Timuta is the Chief Executive Officer for the Florida Association of Healthy
Start Coalitions (FAHSC) and the Healthy Start MomCare Network, Inc. which is the
administrative services organization for FAHSC. She has been in these roles since
October 2018. Prior to working at the state level, Cathy was the Executive Director
for the Healthy Start Coalition of Southwest Florida for 19 years. She was a former
Board President for FAHSC as well as former co-chairs for several committees
including Legislative, Data, Contracts, and Managed Care Organizations
committees. Cathy started her career in Minnesota where she received her MBA in
health care administration. She was the Project Manager for the Minnesota Health Partnership, which
was a collaboration of the state of Minnesota, the Buyer’s Healthcare Action Group (Minnesota’s largest
employers), hospital systems, and health plans. Her passion is to ensure that families have access to
needed healthcare and services to empower parents to give their every baby a healthy start in life.
EVERY BABY DESERVES A HEALTHY START
www.HealthyStartFlorida.com
Cathy Timuta, Chief Executive Officer
History
• In 1991, Healthy Start was signed into law with bi-partisan
support. Goals:
• Reduce infant mortality, low birthweight and support
healthy child development;
• Establish universal prenatal and infant risk screening by
health care providers;
• Establish community-based Healthy Start Coalitions;
• Implement home visiting education and support for
pregnant women and children 0 to 3 years of age.
• In 2001, implemented a Medicaid Waiver to provide Medicaid
funding for Healthy Start services.
• In 2014, included in the Medicaid managed care statute for the
health plans and Healthy Start to coordinate services.
• In 2019, launched a redesigned home visiting model.
• In 2021, Healthy Start celebrates its 30th birthday!
32 Healthy
Start Coalitions
Administer $65 million from DOH and
AHCA to support local maternal and child
health systems of care.
Served more than 200,000 pregnant
women, infants, and their families last year.
HEALTHY START
COALITIONS
Collectively, we:
• Mobilize public and private partners on
our common mission
• Leverage millions of dollars to improve
programs and services for families
• Align efforts with the Florida legislature
to keep them informed of the needs of
its residents and the importance of our
mission
• Serve as a resource for National
maternal and child health initiatives for
dissemination to our thousands of
partners
• Conduct assessments of best practices
and trends to transfer knowledge among
Healthy Start Central & North Central FL our members and our constituents
AHCA
Healthy Start DOH
MomCare Network $24M
$41M Non -Medicaid
Medicaid
Florida’s
HEALTHY START
Funding Structure
32 Healthy Start Coalitions
Local Providers
Universal Prenatal and
Infant Risk Screening
Voluntary, research based, brief
questionnaire proven to identify
pregnant women and infants at risk
for poor birth outcomes.
• Florida Department of Health form
• First opportunity to identify families
at-risk for poor outcomes.
• Last year, 144,952 pregnant women
and 208,016 infants were screened.
Coordinated Intake and Referral (CI&R)
Reduces duplication between home visiting programs, provides family choice of home visiting program,
and connection to additional community supports
Prenatal & Infant Risk Screens
Community & Health Plan
Referrals
HOME VISITING / FACE TO FACE
SERVICES
• RELATIONSHIP-BASED EDUCATION AND
SUPPORT
• Evidence based interventions:
• Perinatal depression
• Substance abuse
• Intimate partner violence
• Health and social emotional
development
• At least 5 home visits prenatally; 8 in
infant’s first year
• Two-gen approach
Early
Outcomes for
New Home
Visiting Model
(Medicaid clients)
FIRST RESULTS! Perinatal Depression Intervention:
Statistically Significant Decrease in Depressive Symptoms
Intervention Group
Control Group
Working With
Families
• Community outreach
• Coordinated intake and
referral
• Home visitation / face to face
services for individualized
education and support
• Group education (community
centers, clinics, churches)
• Community baby showers
• Build relationships with prenatal providers, delivery hospitals, and
Working With pediatricians.
• Monitor universal risk screening rates by clinic and delivery hospital.
Health Care • Educate and support to health providers on screening, latest research, and
Providers client support.
• Provide educational materials for provider distribution.
• Partner with birthing hospitals/centers on intakes and discharges
• Community planning with foundations, Children’s Services Councils, Health Planning
Councils, County Health Departments, health care providers, and more;
Working • Leveraging local funding to support gaps and needs in the community;
With • Engaging the community in collective impact initiatives such as local substance exposed
newborn task forces, fetal and infant mortality reviews, pregnancy mortality reviews, safe
Community sleep initiatives, etc.
Partners • Coordination with health plans;
• Coordination with behavioral health and child welfare partners regarding high-risk clients.
Investing in
Florida’s Children
The highest rate of
return on investment is
during the earliest years
(ages 0‐3)
Thank you for your investment
in giving children a Healthy Start in life
www.HealthyStartFlorida.com
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