Health TeamWorks Guideline for Preconception and Interconception Care

1. Health TeamWorks Guideline for Preconception and Interconception Care June 14, 2011 Presented by: Anna Kelly, MD, Co-Chair of the Health TeamWorks Preconception and Interconception Care GuidelineCommittee and Director, HWHB Preconception Care Working Group

2. Preconception Care Guideline • In Colorado, HealthyWomen-HealthyBabies recognized a need for a guideline for providers to simplify preconception screening and care • In Fall, 2009 we developed a Colorado Preconception Care Guideline in conjunction with Health TeamWorks (formerly the Colorado Clinical Guidelines Collaborative) • In Jan. 2010, they were widely disseminated to providers in a variety of specialties and clinic settings throughout the state.

3. Special Thanks HealthyWomen-HealthyBabies in conjunction with Health TeamWorks received a grant from The Colorado Department of Public Health and Environment (CDPHE) to develop the Preconception and Interconception Care Guideline.

4. Writing Guidelines The Guidelines were developed by using the CDC ‘s evidence-based recommendations published in the Supplement to the American Journal of Ob/Gyn by the Select Panel on Preconception Care in Dec. 2008

5. Guideline Development Committee Committee Members: Co-Chairs: Anna Kelly, MD and Linda Archer, RN, MSN, CNS 1 Neonatologist 2 University of Colorado Medical School Faculty 2 Agency Directors (March of Dimes and Planned Parenthood) 3 Family Practice Physicians 10 Advance Practice Nurses 5 Ob/Gyn Physicians CCGC staff Organizations Represented: CDPHE Healthy Women-Healthy Babies Roundtable March of Dimes Planned Parenthood Kaiser Permanente CO University of Colorado Denver COPIC Insurance Company Rocky Mountain Health Plans St. Joseph Family Medicine Residency Faculty

6. Guideline Development and Implementation Process Committee meetings- every 2 weeks from September - December 2009 Focus group of primary care providers Local and national reviewers HTW member feedback HTW Board and members voted and approved the guideline on December 18, 2009 Disseminated by mail to 4,500 primary care providers including physicians and mid-level practitioners Implementation Plans- Rapid Improvement Activities in the clinical setting

7. Committee Meetings – Process and Intent • The committee reviewed, summarized, simplified, and prioritized the A and B graded recommendations in the CDC Journal Supplement. • As are all of the HTW guidelines, the Preconception Care Guideline is organized as a single page, double-sided, laminated document, also available online with links to other guidelines.

10. Why this topic for a new guideline? • Why should women, menarche to menopause, have preconception screening? • Half of all pregnancies in the United States are unplanned. • Most fetal organs and placental vessels are developing before the first prenatal visit. • Many interventions to prevent birth defects or adverse outcomes must happen before early pregnancy to be effective.

11. Screening Question

12. Screening Factors

14. Contraception Key Barrier Methods: Latex condoms, diaphragm with spermicide, and sponge have a high failure rate with typical use (20-30 pregnancies per 100 women in one year): encourage more effective methods. Condoms are the only contraceptive method that also prevent STIs. When used correctly and consistently, they reduce the risk of infection by 99%. COC: Combined Oral Contraceptives (contains estrogen and progestin). DMPA: Depot Medroxyprogesterone Acetate (progestin only). ETG Implant: Etonogestrel Implant (progestin only). LNG IUD: Levonorgestrel intrauterine device (progestin only). Patch: Combined contraceptive patch (contains estrogen and progestin). POP: Progestin only pills (sometimes referred to as the “mini-pill”). Progestin-Only Emergency Contraception: May be safely used in any woman of reproductive age; there is no medical condition that precludes its use. Ring: Combined vaginal ring (contains estrogen and progestin).

15. Putting Guidelines into Practice • Rapid Improvement Activity (RIA)                 1 hour in length over breakfast or lunch                 Training for the entire practice team                 Guideline content is outlined                 Team brainstorms ideas on integrating   new content and systems change • RIA Results – case study                 In 69 practices in Colorado                      72% of identified goals retained at 3 month follow up

16. Putting Guidelines into Practice • Next Steps and Additional Services offered                 Practice Support (for up to one year)                                 In-office Coaching                                 QI Training and Practice Redesign                 Technology Support Assistance with use of Electronic Health Records                 Secure messaging between patients,                                                 physicians, hospitals, etc                                 Care Management Tool (Registry)                                 Patient Engagement Tool                                 Common Communication Platform

17. Further Questions? Thea Carruth Guidelines Project Manager tcarruth@healthteamworks.org (720) 297-1681 This guideline is designed to assist the clinician in preconception and interconception care and is not intended to replace a clinician’s judgment or establish a protocol for all patients. For references and additional copies of the guideline go to www.coloradoguidelines.org or call 720-297-1681.