71 - Toward City-wide Accountability for Every Newborn: Linking Multiple Primary Care and Social Care Systems to Improve Population Outcomes

Publication Number: 4069.71

CYNTHIA C. WHITE, Cincinnati Children's Hospital Medical Center, Crittenden, KY, United States; Allison Reyner, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Andrew Lovell, Cincinnati Health Department, Cincinnati, OH, United States; Christine M. Burrows, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Emily Miller, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Robert S. Kahn, Cincinnati Children's Hospital Medical Center, CINCINNATI, OH, United States

Background:

Background: Public health and health care collaborate to address infant mortality through population-level measurement and response. No equivalent systems exist to proactively support newborn well-being across a city.

Objective:

Objective: To create accountability and shared action across one birth hospital and three large primary care systems to ensure newborns have an on time first newborn appointment, a joint theory of action and strategic interventions to improve the outcome.

Design/Methods: Methods: Health Commissioner and leaders from the 3 different health systems were convened to form a cross-system improvement team. Quality improvement and learning network methods were used to develop shared vision, SMART Aims, key driver diagram, baseline data, and initial interventions to build shared accountability and action for a population-based denominator of newborns.

Results:

Results: Stakeholders agreed to focus on prenatal care through 2 months of life. We aligned on the AAP's recommended timing of the first newborn visit as a first measure that could serve as a proxy for less easily measurable outcomes. All three systems established baseline rates and set parallel SMART Aims. Baseline rates varied from 49% to 63% (Fig 1). A key driver diagram to improve those outcomes was jointly created (Fig 2). All three systems trained quality improvement leads for this work. Following the KDD drivers, we jointly pursued: establishment of newborn well-being as a Public Health Priority by the Cincinnati Health Commissioner; the data and legal infrastructure to bring together EHR data and shared measures from across systems; formal data linkage with a leading birth hospital to link their newborn discharge data to pediatric visits and to establish a shared approach to risk segmentation; shared assessment of food insecurity in the newborn period to address basic needs (Fig 3); and pilot testing of a new prenatal-newborn partnership with the county public benefits office to optimize timely family public benefits supports (e.g., SNAP, Medicaid).

Conclusion(s):

Conclusions: We successfully identified newborn well-being as a Public Health Priority and built shared accountability and a system for learning across 3 primary care systems and a birth hospital. This collective action facilitated more systemic public benefits response with our county agency.

Figure 1. Key Driver Diagram


Figure 2 Shared Measure Across Three Primary Care systems in Cincinnati
Shared measures to drive population improvement in a City wide learning system

Food insecurity measures at 1 primary care system