STRONG START INITIATIVE IMPROVING MATERNAL AND INFANT HEALTH

On February 8, 2012, the Department of Health and Human Services (HHS) announced the Strong Start initiative to reduce preterm births and improve outcomes for newborns and pregnant women.  This initiative brings together the activities of the Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), the Administration on Children and Families (ACF), Centers for Disease Control, National Institute of Health with the efforts of   outside groups devoted to the health of mothers and newborns including the March of Dimes, the American College of Obstetricians and Gynecologists (ACOG), the National Partnership for Women and Families, the Society for Maternal and Fetal Medicine, the American College of Nurse Midwives, Childbirth Connections, Leapfrog Group, the National Priorities Partners, convened by the National Quality Forum, and others.   

Strong Start includes two components:

1. A test of a nationwide public-private partnership and awareness campaign to spread the adoption of best practices that can reduce the rate of early elective deliveries prior to 39 weeks for all populations; and
2. An initiative to reduce the rate of preterm births for women who are at-risk for preterm birth and covered by Medicaid through testing enhanced prenatal care models.

I. Reducing the rate of early elective deliveries

The American College of Obstetricians and Gynecologists (ACOG) has advocated against early elective deliveries for more than 20 years.  Numerous studies have demonstrated that early elective deliveries – those performed prior to 39 weeks without a medical indication – are associated with increased maternal and neonatal complications for both mothers and newborns as compared to deliveries occurring after 39 weeks gestation.  Despite this information, elective deliveries prior to 39 weeks may still account for more than 10 percent of all deliveries.  

Reducing the rate of early elective deliveries prior to 39 weeks ensures that more mothers receive safe, evidence-based care, and improves the prospects for good physical and developmental health for infants. It also reduces costs by safely reducing preventable C-section rates, neonatal intensive care admissions and other associated complications.

The Strong Start intiative will leverage the existing infrastructure of the Partnership for Patients, including the participating Hospital Engagement Networks, to support hospitals across the country in their efforts to decrease the number of early elective deliveries and improve outcomes for mothers and infants. 

The Partnership for Patients is a nationwide public-private collaboration sponsored by HHS to improve the quality, safety, and affordability of health care for all Americans.  Launched in April 2011, the Partnership for Patients now consists of more than 7,200 partners, including over 3,200 hospitals, who have pledged to work together to reduce the number of hospital-acquired conditions by 40 percent and reduce hospital readmissions by 20 percent by the end of 2013.   As part of the collaboration, CMS awarded funding in December 2011 to 26 National, State, and Regional hospital system organizations to serve as Hospital Engagement Networks.  Hospital Engagement Networks will work to develop learning collaboratives for hospitals so that they can implement the changes and innovations necessary to achieve the Partnership for Patients’ safety and care transitions goals. Improving obstetrical outcomes, which includes reducing early elective deliveries, is one of the goals of the Partnership for Patients.

To help achieve these aims, HHS will employ three specific strategies:

1. Implementing a quality improvement platform through Partnership for Patients to share best practices, provide technical assistance to hospitals in implementing and adapting the practices and report data.
2. Creating support for change with a broad-based campaign to engage providers, patients, and the public, working with organizations such as the March of Dimes and ACOG. 
3. Supporting efforts to collect performance data, measure success, promote transparency and continuous improvement.

The evaluation efforts will be supported through the expansion and use of the Partnership for Patients’ Organizational Assessment Tool, which will survey participating hospitals on a range of issues, including policy and performance relative to early elective delivery prior to 39 weeks.

II. Reducing the rate of preterm births for at risk women covered by Medicaid

As part of the Strong Start initiative, CMS released a funding opportunity announcement to reduce the frequency of premature births – medically defined as less than 37 weeks of gestation – among pregnant beneficiaries at-risk for preterm births.   Under this initiative, the Innovation Center will award up to $43 million through a competitive process to providers, States, managed care plans, and conveners to achieve better care, improved health, and lower costs for these women and their newborns. 

The Strong Start grant funding opportunity is a four-year initiative to test and evaluate the effect enhanced prenatal care has on decreasing prematurity.  This initiative will test three evidence-based approaches to the delivery of enhanced prenatal care and better understand how behavioral and psychosocial factors may contribute to poor birth outcomes.  The goal of the initiative is to determine if these approaches to care can impact the rate of preterm births, improve the health outcomes of pregnant women and newborns and decrease the total cost of medical care for mothers and their infants.

The Innovation Center will offer grant funding for to test three approaches:

1. – group prenatal care that incorporates peer-to-peer interaction in a facilitated setting for health assessment, education, and provides psycho-social support.   

1. – comprehensive prenatal care facilitated by teams of health professionals including peer counselors and doulas.  Services include collaborative practice, intensive case management, counseling and psycho-social support. 

1. – enhanced prenatal care including psychosocial support, education, and health promotion in addition to traditional prenatal care.    Services provided will expand access to care, improve care coordination and provide a broader array of health services. 

Interested parties can propose to implement more than one approach, but only one option can occur at an individual practice.  We encourage applicants to review the funding opportunity announcement and carefully consider each option and its fit with their organizational structure and capacity. 

The Innovation Center, in partnership with HRSA and ACF will also evaluate a fourth approach to preventing preterm births, the enhanced prenatal care through home visiting, as part of the Maternal, Infant, and Early Childhood Home Visiting program, building on the program and evaluation already started for that program.   

Monitoring and Evaluation

The awardees of the Strong Start grant opportunity must participate in monitoring and evaluation activities to ensure that quality care is being delivered.  For example, the awardees will be expected to provide to the Innovation Center on a monthly basis metrics that are consistent with the goals of the initiative.  At a minimum, awardees will report information on: gestational age at delivery, birth weight, and use of Neonatal Intensive Care Units (NICUs).  These reports will also include claims data for enrollees in managed care and data that allow linkage between mothers and infants. 

Awardees are also required to submit semi-annual progress reports providing, at a minimum, the specific uses of the cooperative agreement funds and an assessment of the overall project implementation.  Awardees must also submit quarterly data reporting on operations, utilization, and outcomes.

CMS will provide technical assistance, analytic support, and coordination to help awardees launch their interventions to reduce premature births.  As with all Innovation Center initiatives, awardees should plan to participate in opportunities for shared learning and dissemination with others. 

Cooperative Agreement Structure

CMS will award, through a competitive process, a set of renewable one year cooperative agreements to eligible applicants.  Strong Start will operate for three years, and there will be up to an additional one year beyond the last birth for data collection and submission.  Up to $43 million will be available for this initiative.  The number of awards will depend on the number of women that applicants can enroll.  The Innovation Center intends to fund the cost of additional enhanced prenatal services for approximately 30,000 pregnant Medicaid beneficiaries in each of the three options, or care for approximately 90,000 women in total over three years. 

Funds will be awarded with consideration to:

• Available funding
• Geographic diversity
• Quality of each application and the ability to meet the goals of the initiative

Each applicant should have the capacity to serve at least 500 pregnant Medicaid beneficiaries considered at-risk for a preterm birth each year. 

Funds shall not be used to cover Strong Start service delivery operations after the third year. 

Eligibility Criteria

The intent of this initiative is to engage with a wide variety of interested parties who have developed innovations to improve care, improve health, and lower costs for Medicaid beneficiaries who are pregnant and at-risk of preterm births.  Eligible applicants include:

1. Providers of obstetric care (e.g. provider groups or affiliated providers and facilities)
2. State Medicaid Agencies
3. Medicaid managed care organizations (MCOs)
4. Conveners in partnership with other applicants.  The convener may be a direct applicant, or may convene and support other organizations to become applicants.  Examples of conveners include States, associations of providers or other health service related organizations. 

Non-State organization proposals must include a letter from the State Medicaid agency affirming that the State will co-sign an agreement between CMS and the entity upon selection as an awardee.  This is necessary to ensure that all applicants and States implement interoperable data systems to identify eligible Medicaid beneficiaries and participate actively in data collection, reporting, and transmittal operations for the life of the initiative. All non-provider applicants must also include letters from their provider partners to demonstrate willingness and capacity to participate in this initiative.  Partnerships with maternal/child health, public health and community-based organizations as well as multistate collaborations are also encouraged to apply. 

All applications must be submitted electronically through http://www.grants.gov.   Applicants are strongly encouraged to use the review criteria information provided in the “Application Review Information” section in the funding opportunity announcement, to help ensure that the proposal adequately addresses all the criteria that will be used in evaluating the proposals.

Important Deadlines

Letter of Intent:  March 21, 2012, by 5:00 pm EST

Applications are due:  June 13, 2012, by 5:00 pm EST

Anticipated Award Date:  September 10, 2012

About the Innovation Center

The Innovation Center was created by the Affordable Care Act to test new innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care.  The Innovation Center is committed to transforming the Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) to deliver better care for beneficiaries, better health for populations and slower growth in expenditures through improvement for beneficiaries. 

For More Information

For more information, please refer to the Strong Start grant funding opportunity announcement found at: http://innovation.cms.gov/initiatives/strong-start.    

For specific questions, please send an email to StrongStart@cms.hhs.gov.

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