Texas AIM: A Q&A with Dr. Manda Hall

Manda Hall, M.D., is Associate Commissioner for Community Health Improvement at the Texas Department of State Health Services. She is also the state’s point person on the development and implementation of TexasAIM, a new initiative focused on reducing maternal mortality and morbidity in Texas.

We spoke to Dr. Hall, who is on the TCHMB executive committee, about the background to TexasAIM, maternal mortality and morbidity in Texas, and what TexasAIM will look like over the next few years.

Hall received her Medical Degree from Texas A&M University Health Science Center College of Medicine, and completed her residency and fellowship at the University of Alabama at Birmingham. She graduated as fellow from the Maternal and Child Health Leadership Institute at the University of North Carolina at Chapel Hill and is a faculty member of the DSHS Preventative Medicine and Public Health Residency Program.

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Before we talk about TexasAIM, specifically, I’d like to ask you about maternal mortality rates in Texas, and the controversy around that. What’s the pre-history to TexasAIM, in other words?

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There has been a lot of discussion, nationally, about maternal mortality rates. Both because they are tragic, in themselves, and because they are important indicators of maternal health more broadly. We know that for every maternal death, there are 50-100 cases of severe maternal morbidity.

There has been a great deal of focus on this issue in Texas because there was a study published in 2016 that identified the rate of maternal mortality in Texas for 2012 as being exceptionally high. In May of this year, we published a new study of maternal deaths in Texas for that same year, using an enhanced method, that provided a more accurate estimate of the maternal mortality rate. The revised rate was 14.6 maternal deaths per 100,000 live births, which is less than half of what had been previously published.

While our study showed the rate of maternal mortality to be far less than what it was, our findings are not reason to lose focus on the importance of reducing maternal mortality and morbidity. The rate is still too high, especially when we compare it to the Healthy People 2020 target of 11.4. When we look even closer at the data, we see that African-American women continue to bear the greatest risk for maternal mortality—more than twice as high as among hispanic and white women. We still have work to do.

Which brings us to TexasAIM. What is it?

It is a good example of what public health calls “data to action”. We are using the data and the knowledge gained and utilizing it to implement public health programming.

In this case, we are implementing a series of maternal safety bundles that were developed by the Alliance in Maternal Health, or AIM. It is a national program, overseen by the American College of Obstetrics and Gynecology (ACOG), that was developed with input and guidance from a broad group of partner organizations and experts.

These maternal safety bundles have been implemented in other states, and have led to a significant reduction in severe maternal morbidity, and in some cases, in mortality as well. We are now working to implement them here in Texas, and that, in a nutshell, is TexasAIM.

Before getting deeper into the details of TexasAIM, can you tell me what a “bundle” is, in this context?

A bundle isn’t comprised of a single item or guidance or intervention. Rather, it is a collection of resources aimed at achieving a specific goal. It includes items like checklists, best practices, and example protocols. You bring those together so they can be utilized by a team to improve outcomes. They’re designed not only to emphasize evidence-based interventions and strategies, but also to be flexible enough to be deployed differently in different contexts.

TexasAIM is focused on implementing three bundles: obstetric hemorrhage, obstetric care for women with opioid use disorder, and severe hypertension in pregnancy.

What does that mean in practice, for hospitals in Texas?

We now have more than 180 hospitals enrolled in the program, which represents more than two thirds of all the birthing hospitals in Texas, or approximately 82% of the births in our state.

Each hospital is enrolled in either AIM Basic or AIM Plus. Hospitals enrolled in AIM Basic have access to resources and technical assistance. They will report measures to the AIM portal, and have access to that data. They will form an improvement team, and will have the opportunity to transition to AIM Plus if or when it makes sense for them.

Texas is vast and varied, so one of the key elements of our strategy is to think regionally. The AIM Plus hospitals are being divided into five cohorts, by geography, with 20-30 hospitals in each cohort. Each hospital will receive in-person learning sessions, from DSHS. They will do an intake assessment, implement the bundles, and track and share process and outcome data over time, which will allow us and the hospitals to measure change. The cornerstone of all of this is the ongoing learning collaboratives among the hospitals in each cohort.

We recognize that hospitals are starting in different places. We have hospitals that have already implemented many of the elements of the bundles, while others aren’t as far along. The collaboratives will facilitate the hospitals learning from each other, sharing expertise and knowledge, and working through challenges.

Is it all voluntary?

Yes. Both levels of TexasAIM are voluntary programs for hospitals who are interested in participating. There is no penalty for not participating.

There is the opportunity, however, to use the implementation of these bundles to meet the requirements for neonatal and maternal levels of care designation, which will be required for Medicaid reimbursement beginning this fall for neonatal designation, and in 2020 for maternal designation.

To meet the requirements, hospitals must have a Quality Assessment and Performance Improvement process in place. It doesn’t have to be TexasAIM, but it can be.

So no stick, but a carrot.

Yes. More important, though, is the general recognition throughout the state that these are issues of extraordinary importance, and that this is a meaningful way to address them. The level of participation and collaboration is a testament to that. We have worked closely with the Maternal Mortality and Morbidity Taskforce, Texas Collaborative for Healthy Mothers and Babies, Texas Medical Association, Texas Nursing Association, ACOG, and the Texas Hospital Association. At our leadership summit on June 4th, which was the formal launch of TexasAIM, there were representatives from over 150 hospitals. We now have more than 180 hospitals enrolled. That is an exceptional level of participation for a state as big and diverse as Texas.

So what now?

As hospitals are enrolling, they are doing the intake assessments, to get a measure of where they are starting from. We are beginning with the bundle on obstetric hemorrhage. Then we’ll phase in the hypertension in pregnancy bundle. The opioid use disorder bundle is still in development at the national level, and we have been invited by the AIM program to participate with other states and experts on the final development of that bundle. We will implement that bundle as a pilot beginning this summer, with the goal of implementing this bundle statewide in spring to early summer of 2019.

How will you measure success?

By tracking the data over time, we hope to see marked reductions in maternal morbidity. It is possible we will see a decline in maternal mortality as well, but maternal deaths, although terribly tragic, are rare events, so it is harder to see statistically meaningful shifts in that rate over short periods of time.

Any final thoughts?

We need to insure that the family voice is present in the work we were doing. At the TexasAIM summit, we were fortunate enough to have mothers and fathers present who shared what had happened to themselves or their loved one who had died from complications during pregnancy and delivery. Some even spoke directly to hospital representatives who were in the audience, asking for change, and it was really powerful and profound. This isn’t just about numbers and best practices. It’s about keeping women alive and healthy, and keeping families whole.