A Mayo Clinic prenatal program takes a new approach to improving care for women with low-risk pregnancies.

Two-year-old Quinn Hales confidently places her toy stethoscope against baby sister Finley's chest to listen to her heartbeat. It's a skill she's been honing ever since Finley was just a curiosity in her mom's belly.

When the girls' mother, Sian Hales, was pregnant with Finley, she participated in a program at Mayo Clinic called OB Nest. It seeks to improve the patient experience by reducing the number of prenatal appointments from between 12 and 14 to just eight for low-risk pregnancies.

Expectant mothers with low risks of pregnancy complications are given home monitoring devices to check the baby's heart rate and the mother's blood pressure between appointments. They also have access to an online care community, nurses and a nurse call line to answer questions between visits.

"When we noticed patient satisfaction was declining, we wanted to find a better way to care for expecting moms." — Abimbola Famuyide, M.B.B.S.

"Quinn loved it," Sian says. "Sometimes it would be days before our scheduled monitoring check, and she would ask, 'Are we going to check the baby's heartbeat today?' She would get the jelly for me and sit by me as we found the heartbeat together."

The concept for OB Nest was born out of concerns that the traditional approach to prenatal care — a fixed schedule of 12 to 14 short visits to check for a steady heartbeat and growing baby — no longer was meeting patients' needs and was creating more burden than assurances for the patient and families.

"When we noticed patient satisfaction was declining, we wanted to find a better way to care for expecting moms," says Abimbola Famuyide, M.B.B.S., chair of the Mayo Clinic Department of Obstetrics and Gynecology.

The clinical team found the help they needed in Mayo Clinic research and design groups. The Department of Obstetrics and Gynecology partnered with service designers in the Center for Innovation, who developed and tested several options aimed at improving the care experience for moms.

Results of this work informed the proposed new model of care — the OB Nest. The model was then evaluated in a clinical trial by researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. This team assessed patient outcomes, and evaluated patient and staff perspectives on the new model in practice. Results from the clinical trial found that women had the same quality of care as those who received traditional care, but they had higher satisfaction and less stress and anxiety.

"This fulfills the holy grail of what patients expect today," Dr. Famuyide says. "It expands choices for women and gives them the opportunity to pick what works best for them. That improves patient experience and clinical outcomes, while at the same time keeping costs down."

"I could check my weight and blood pressure in the comfort of my PJs, knowing that if I had any questions or problems, I could just call and talk to a nurse." — Sian Hales

Sian can attest to these benefits. When she was pregnant with her older daughter, Quinn, Sian and her husband, Aaron, had difficulty coordinating prenatal appointments with Aaron's work schedule — and they needed to make arrangement for someone to watch their school-age sons, Easton and Grayson.

"With Finley, it was nice being able to stay home and not always have to find a sitter for appointments," Sian says. "I could check my weight and blood pressure in the comfort of my PJs, knowing that if I had any questions or problems, I could just call and talk to a nurse. And if there was a problem, I could come in. It was always nice to have that comfort."

Note: A version of this story was previously published in Mayo Clinic Magazine.

HELPFUL LINKS

• Learn more about prenatal care and healthy pregnancy.
• Read about the Department of Obstetrics and Gynecology.
• Explore Mayo Clinic.
• Request an appointment.

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Sian Hales gave birth to her fourth child in June 2017, but the experience was different this time. She received much of her prenatal care at home. And she performed much of this care herself.

Instead of making a dozen or so appointments and driving to the clinic for each, she sat comfortably in her living room. When it was time to check her blood pressure and the fetal heart rate, she did so herself, using equipment provided by the Mayo Clinic OB Nest program.

OB Nest, established at Mayo Clinic in 2016, changes pregnancy for low-risk expectant mothers from a highly clinical process to a personalized wellness experience. It reduces the number of planned clinical visits to no more than eight, and provides mothers with
a fetal heart rate monitor and blood pressure cuff for home monitoring. Patients also can access an online community moderated by OB Nest nurses and call those nurses whenever questions arise.

For Sian, the program couldn’t have worked better. She says she felt more engaged and comforted in that she could always pick up the phone and talk to an OB Nest nurse. The equipment was easy to use, she says, and, by the end, her 2-year-old daughter, Quinn, was an active participant.

“Is it time to check the baby’s heartbeat?” Quinn would ask excitedly.

Though Sian and hundreds of other moms who participate in OB Nest may not realize it, the program is based on a series of collaborations between the Mayo Clinic Department of Obstetrics and Gynecology and the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. Working with Mayo’s Office of Information and Knowledge Management, they found a better way to track patients who were at high risk and those who weren’t. With human-centered design techniques from the Mayo Clinic Center for Innovation, researchers explored creative patient-provider models.
And finally, a research team conducted a randomized clinical trial to test a new model of delivering prenatal care. In Obstetrics and Gynecology, Mayo researchers reported that the program decreased in-office visits, increased patient satisfaction and reduced stress for expectant mothers.

“It was great for me with four kids, and nice being able to stay at home and feel like I’m a part of the process,” Sian says.

By gathering data like this, the Kern Center works directly with health care providers to make broad improvements to patient care.

ENGINEERING EMERGENCY MEDICAL CARE
Kalyan Pasupathy, Ph.D., had heard for years about the engineering principles at Mayo Clinic and was always curious. So when the need arose to improve delivery of care at Mayo, using data and decision science, he jumped at the opportunity. The project? Improve efficiency in the complex environment of the Emergency Department.

“It’s been the highlight of my career,” says Dr. Pasupathy of this engineering work in the Kern Center.

In 2013, Dr. Pasupathy was the scientific director for Mayo’s Emergency Department Clinical Engineering Learning Laboratory, or ED-CELL. Working side by side with the team’s medical director, Thomas Hellmich, M.D., and other emergency personnel, the team installed radio frequency identification (RFID) technology throughout the department.

In the Emergency Department the RFID tags instantly locate patients, equipment and staff. After installing 194 ceiling-mounted readers across Mayo’s 54,500-square-foot Emergency Department, the research team developed software to access the data both in real time and for later analysis.

The result is what the team calls a fully searchable Emergency Department.

The technology offers myriad benefits. In the Annals of Emergency Medicine, the team reported that RFID tagging could reduce wasted time searching for patients, equipment and staff by 87 percent. This not only speeds care, but represents a potential savings of $1.87 million annually.

RFID tags also are used to analyze patient wait time and the time health care providers spend with patients to look for ways to improve both. And the technology can also help trace anyone who came in contact with patients who have particularly contagious pathogens. A Mayo study, published in the American Journal of Infection Control, found 45 additional staff members from nine pertussis (also called whooping cough) cases who wouldn’t have been identified using the standard method.

Mayo researchers are now using these engineering principles in other departments, launching a Radiology CELL last year. These initiatives are due to the collaborative nature of a CELL, where traditional barriers between research and medical practice are torn down, says Dr. Pasupathy.

THE IDEAL DOSE
Just down the hall from Dr. Pasupathy, Elizabeth Habermann, Ph.D., works on improving surgical outcomes. Front and center for her team is an issue overwhelming medical centers, politicians and health organizations across the United States: the opioid epidemic.

Since 1999, drug-overdose deaths have trended up nationally, nearly tripling in the 15-year period from 1999 to 2014. From 2014 to 2015, they continued to rise (11.4 percent) and 60.9 percent of those deaths involved an opioid according to the Centers for Disease Control and Prevention.

“There’s an urgency to address the opioid epidemic,” Dr. Habermann says. “Surgeons know a small amount of their patients become dependent, and we want to reduce that number.”

The need for evidence-based guidelines for prescribing opioids after surgery is quickly emerging. Dr. Habermann and a team of surgeons, nurses, pharmacists and pain specialists are studying Mayo Clinic’s prescribing practices in hopes of optimizing prescriptions. Their initial research, published in the Annals of Surgery, shows a wide variation within specific surgery types and among Mayo Clinic campuses in Arizona, Florida and Minnesota — even after adjusting for other factors. The median opioid prescription on all campuses equaled 50 pills of 5-milligram oxycodone, which is almost twice the amount draft guidelines from the state of Minnesota recommend for
a maximum. Though the guidelines were not released at the time of the study, 4 in 5 prescriptions exceeded the recommended amount, which presented an opportunity for improvement.

“Mayo is unique in that we have a large volume surgical practice,” Dr. Habermann says. “So it’s an opportunity to be transparent about our prescribing data, and use that data to improve our practice and help other institutions do the same.”

By shining a light on Mayo’s prescribing, Dr. Habermann’s research team is showing the need for an evidence base to use when establishing guidelines. Using this research, Mayo Clinic’s departments of Obstetrics and Gynecology, Neurologic Surgery and Orthopedic Surgery have begun developing guidelines.

But the research team isn’t stopping there. They’re surveying 2,500 patients to determine which demographics and surgery types have an abundance of leftover medication and how well patients are managing their pain.

“This research isn’t about taking away opioid prescriptions from patients who need them after surgery,” Dr. Habermann says. “This is about optimizing prescriptions for every unique patient, so everyone has enough to manage the pain but also to reduce the leftover pills in the medicine cabinet at home, which can lead to diversion.”

“Collaborating across specialties at Mayo, we’re forging our own path,” she says. “While it’s challenging, it’s rewarding and hopefully helps patients both within and outside of Mayo.”

- Adam Harringa, February 5, 2018

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On Mayo Clinic Radio, Dr. Ed Laskowski, co-director of Mayo Clinic Sports Medicine Center, has tips on how to get started with a running routine, as well as the benefits of interval training. Also on the program, Mayo Clinic obstetrician Dr. Yvonne Butler Tobah discusses advances in prenatal care, including Mayo Clinic's novel approach — dubbed OB Nest — for women with low-risk pregnancies. And, Mayo Clinic family medicine specialist Dr. Elizabeth Cozine explains the viral infection known as shingles.

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Listen to the program on Saturday, June 18, at 9:05 a.m. CDT.

Miss the show?  Here's the Mayo Clinic Radio podcast.

Follow #MayoClinicRadio, and tweet your questions.

Mayo Clinic Radio is on iHeartRadio.

Mayo Clinic Radio produces a weekly one-hour radio program highlighting health and medical information from Mayo Clinic.

Access archived shows.

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ROCHESTER, Minn. — “OB Nest”: Just the name may bring warm feelings to parents and prospective parents. However, at Mayo Clinic, it’s much more than a name. It’s a new way that Mayo Clinic is providing prenatal care. And, families say they are thrilled with the process.

Current prenatal care for a pregnancy consists of 12-14 visits with an obstetrician. However, often these visits are just brief check-ins to make sure a pregnancy is progressing well. Previous research has looked at ways to give providers more time for high-risk patients, and save time and office visits for women with low-risk pregnancies. While these studies have shown that less visits are safe, patients reported less satisfaction overall.

Seeking to identify ways to improve patient experience and perceived value, Mayo Clinic researchers decided to test a new way of providing prenatal care, dubbed “OB Nest.”

MEDIA CONTACT:  Elizabeth Zimmermann Young, Mayo Clinic Public Affairs, 507-284-5005, newsbureau@mayo.edu

With the changes to the care experience provided within OB Nest, the researchers found that not only did patient satisfaction improve, but also this improved satisfaction came with fewer office visits. They will present their findings in an oral presentation during the 2016 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists (ACOG), May 14-17, 2016.

“Traditionally, pregnancy is treated as a sickness,” says Yvonne Butler Tobah, M.D., a Mayo Clinic obstetrician and lead author of this study. “We wanted our care to reflect the normal, life-bringing event that it is, and [we] looked for a way to transform prenatal care into a wellness, patient-oriented experience.”

The Department of Obstetrics and Gynecology, in collaboration with the Center for Innovation, worked with patients and staff to collect and prioritize ideas to improve the way pregnant women and their families experience prenatal care. Along with the department, the Care Experience Program, which is part of the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, took this information and these ideas and designed evidence-based practice improvements for prenatal care.

OB Nest study participants – all of whom were experiencing low-risk pregnancies – entered the program with a specific nurse identified as their lead contact. They received eight scheduled office visits (More were optional.) and home monitoring equipment for fetal heart rate and maternal blood pressure. In addition, they could take part in an online care community with other OB Nest participants and nurses from the OB Nest care team.

“My schedule is very hectic,” says Seri Carney, M.D., a mom who participated in the OB Nest study during pregnancy with her second child. “It was really nice to only have to go in for my appointments every other month. My husband and I didn’t have to worry as often about arranging our work schedules for the appointments.”

“We could listen to the heartbeat whenever we wanted,” says Dr. Carney. “Our daughter was 4 at the time, and doing it at home meant that she could get involved, too. That was really fun. It also felt like it made me more aware of the movements and heartbeat of my baby.”

In her third trimester, when Dr. Carney noticed her baby’s heartbeat was a little low, she was able to email her care team. They reacted right away and got Carney in for a stress test. All was fine, and within a few weeks, she and her family welcomed baby Luisa Jane.

The OB Nest research project is part of Mayo Clinic’s health care delivery research efforts, and aligns with the Institute for Healthcare Improvement Triple Aim.

“This fulfills the holy grail of what patients expect today,” says Abimbola Famuyide, M.B.B.S., chair of the Department of Obstetrics and Gynecology, and study principal investigator. “How can we continue to improve patient experience and clinical outcomes, while, at the same time, keep costs down?”

“Improving the patient experience, in the case of OB Nest, includes empowering expectant women to truly engage in, and take control of, their care,” says Dr. Famuyide. He and his team learned that having one nurse as the center point for each woman’s care and concerns provided them the comfort of easy connection. Concurrently, fewer office visits saved health care provider resources, while reducing patient burden.

This practice transforming research is leading to permanent changes in the way women receive prenatal care across Mayo Clinic. It is part of the goal of the Mayo Model of Community Care, to deliver wellness-focused, high-value health care – improving access, convenience and patient satisfaction, while lowering costs.

The OB Nest research team is led by:

• Dr. Famuyide, principal investigator
• Annie LeBlanc, Ph.D., co-principal investigator

Co-investigators are:

• Bobbie Gostout, M.D.
• Roger Harms, M.D.
• Dr. Butler Tobah
• Ellen Brodrick, A.P.R.N., C.N.M.
• Vanessa Torbenson, M.D.
• Susan Sobolewski, R.N.
• Anne Baron, R.N.
• Misty Baker, R.N.
• Angela Sivly, C.C.R.P.
• Nancy Jo Knutson, R.N.
• Katie Slifko, M.S.N., R.N.
• Maureen Lemens, R.N.
• Susan Stirn, M.S.N., R.N., N.E.A.-B.C.
• Jennifer Ridgeway
• Jonathan Inselman
• Megan Branda
• Megan Morris, Ph.D.
• Dawn Finnie
• Katharine Nesbitt

ACOG awarded the researchers  second prize in the scientific program for 2016. In addition to the presentation at ACOG, the team is presenting two posters at AcademyHealth’s Annual Research Meeting June 26-28.

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