Brian W. Jack

The clinical content of preconception care: women with chronic medical conditions.

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures

Substance abuse poses significant health risks to childbearing-aged women in the United States and, for those who become pregnant, to their children. Alcohol is the most prevalent substance consumed by childbearing-aged women, followed by tobacco, and a variety of illicit drugs. Substance use in the preconception period predicts substance use during the prenatal period. Evidence-based methods for screening and intervening on harmful consumption patterns of these substances have been developed and are recommended for use in primary care settings for women who are pregnant, planning a pregnancy, or at risk for becoming pregnant. This report describes the scope of substance abuse in the target population and provides recommendations from the Clinical Working Group of the Select Panel on Preconception Care, Centers for Disease Control and Prevention, for addressing alcohol, tobacco, and illicit drug use among childbearing-aged women.

The clinical content of preconception care: infectious diseases in preconception care.

A number of infectious diseases should be considered for inclusion as part of clinical preconception care. Those infections strongly recommended for health promotion messages and risk assessment or for the initiation of interventions include Chlamydia infection, syphilis, and HIV. For selected populations, the inclusion of interventions for tuberculosis, gonorrheal infection, and herpes simplex virus are recommended. No clear evidence exists for the specific inclusion in preconception care of hepatitis C, toxoplasmosis, cytomegalovirus, listeriosis, malaria, periodontal disease, and bacterial vaginosis (in those with a previous preterm birth). Some infections that have important consequences during pregnancy, such as bacterial vaginosis (in those with no history of preterm birth), asymptomatic bacteriuria, parvovirus, and group B streptococcus infection, most likely would not be improved through intervention in the preconception time frame.

The Clinical Content of Preconception Care: Genetics and Genomics

The prevalence of paternal and maternal genetic conditions that affect pregnancy varies according to many factors that include parental age, medical history, and family history. Although some genetic conditions that affect pregnancy are identified easily early in life, other conditions are not and may require additional diagnostic testing. A complete 3-generation family medical history that includes ethnicity information about both sides of the family is arguably the single best genetic test that is applicable to preconception care. Assessment of genetic risk by an experienced professional has been shown to improve the detection rate of identifiable risk factors. Learning about possible genetic issues in the preconception period is ideal, because knowledge permits patients to make informed reproductive decisions. Options that are available to couples before conception include adoption, surrogacy, use of donor sperm, in vitro fertilization after preimplantation genetic diagnosis, and avoidance of pregnancy. Future technologic advances will increase the choices that are available to couples.

The clinical content of preconception care: immunizations as part of preconception care

Many vaccine-preventable diseases have serious consequences for the pregnant mother, the fetus, and the neonate. This article reviews the rationale and impact of including vaccinations as part of preconception care and provides recommendations for clinical care. Vaccinations that are recommended highly in preconception care include the hepatitis B and the measles, mumps, and rubella vaccines. The role of human papillomavirus, varicella, diphtheria, tetanus, and pertussis vaccinations as part of preconception care is also discussed.

How Hospitals Reengineer Their Discharge Processes to Reduce Readmissions.

Background:The Re-Engineered Discharge (RED) program is a hospital-based initiative shown to decrease hospital reutilization. We implemented the RED in 10 hospitals to study the implementation process. Design:We recruited 10 hospitals from different regions of the United States to implement the RED and provided training for participating hospital leaders and implementation staff using the RED Toolkit as the basis of the curriculum followed by monthly telephone-based technical assistance for up to 1 year. Methods:Two team members interviewed key informants from each hospital before RED implementation and then 1 year later. Interview data were analyzed according to common and comparative themes identified across institutions. Readmission outcomes were collected on participating hospitals and compared pre- versus post-RED implementation. Results:Key findings included (1) wide variability in the fidelity of the RED intervention; (2) engaged leadership and multidisciplinary implementation teams were keys to success; (3) common challenges included obtaining timely follow-up appointments, transmitting discharge summaries to outpatient clinicians, and leveraging information technology. Eight out of 10 hospitals reported improvement in 30-day readmission rates after RED implementation. Conclusions:A supportive hospital culture is essential for successful RED implementation. A flexible implementation strategy can be used to implement RED and reduce readmissions.

Components of Comprehensive and Effective Transitional Care

Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients’ and caregivers’ needs and experiences. To address this gap, the Patient‐Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient‐centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real‐world patients and caregivers experiences. Through this process, the workgroup identified eight TC components: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients and caregivers well‐being, care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.

Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study

BackgroundProject Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country. To date, little is known about how adapting Project RED from its original protocol impacts RED implementation and/or sustainability. The goal of this study was to identify and characterize contextual factors influencing how five California hospitals adapted and implemented RED and the subsequent impact on RED program sustainability.MethodsParticipant observation and key informant and focus group interviews with 64 individuals at five California hospitals implementing RED in 2012 and 2013 were conducted. These involved hospital leadership, personnel responsible for Project RED implementation, hospital staff, and clinicians. Interview transcripts were coded and analyzed using a modified grounded theory approach and constant comparative analysis.ResultsBoth internal and external contextual factors were identified that influenced hospitals’ decisions on RED adaptation and implementation. These also impacted RED sustainability. External factors included: impending federal penalties for hospitals with high readmission rates targeting specific diagnoses, and access to external funding and technical support to help hospitals implement RED. Internal or organizational level contextual factors included: committed leadership prioritizing Project RED; RED adaptations; depth, accountability and influence of the implementation team; sustainability planning; and hospital culture. Only three of the five hospitals continued Project RED beyond the implementation period.ConclusionsThe sustainability of RED in participating hospitals was only possible when hospitals approached RED implementation as a transformational process rather than a patient safety project, maintained a high level of fidelity to the RED protocol, and had leadership and an implementation team who embraced change and failure in the pursuit of better patient care and outcomes. Hospitals who were unsuccessful in implementing a sustainable RED process lacked all or most of these components in their approach.

Follow-up after gestational diabetes: a fixable gap in women’s preventive healthcare

Objective Gestational diabetes mellitus (GDM) is a known harbinger of future type 2 diabetes mellitus (T2DM), hypertension, and cardiac disease. This population-based study was designed to identify gaps in follow-up care relevant to prevention of T2DM in a continuously insured sample of women diagnosed with GDM. Research design and methods We analyzed data spanning 2005–2015 from OptumLabs Data Warehouse, a comprehensive, longitudinal, real-world data asset with deidentified lives across claims and clinical information, to describe patterns of preventive care after GDM. Women with GDM were followed, from 1u2009year preconception through 3u2009years postdelivery to identify individual and healthcare systems characteristics, and report on GDM-related outcomes: postpartum glucose testing, transition to primary care for monitoring, GDM recurrence, and T2DM onset. Results Among 12u2009622 women with GDM, we found low rates of glucose monitoring in the recommended postpartum period (5.8%), at 1u2009year (21.8%), and at 3u2009years (51%). A minority had contact with primary care postdelivery (5.7% at 6u2009months, 13.2% at 1u2009year, 40.5% at 3u2009years). Despite increased population risk (GDM recurrence in 52.2% of repeat pregnancies, T2DM onset within 3u2009years in 7.6% of the sample), 70.1% of GDM-diagnosed women had neither glucose testing nor a primary care visit at 1u2009year and 32.7% had neither at 3u2009years. Conclusions We found low rates of glucose testing and transition to primary care in this group of continuously insured women with GDM. Despite continuous insurance coverage, many women with a pregnancy complication that portends risk for future chronic illness fail to obtain follow-up testing and may have difficulty navigating between clinician specialties. Results point to a need for action to close the gap between obstetrics and primary care to ensure receipt of preventive monitoring as recommended by both the American Diabetes Association and the American Congress of Obstetricians and Gynecologists.

Care Transitions From Patient and Caregiver Perspectives

PURPOSE Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them. METHODS We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them. RESULTS Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient’s needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs. CONCLUSIONS Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.