Midwifery Continuity Of Carer Model Tool-kit - Ministry Of Health

Maternity-Towards Normal BirthPolicy Directive PD2010-045Annualised SalaryA pilot agreement for a Midwifery Caseload PracticeThis policy provides direction to NSW maternity servicesAnnualised Salary Agreement (the Agreement) has beenregarding actions required to increase the vaginal birthdeveloped in NSW between the NSW Nurses Associationrate and decrease the caesarean section operation rate;and the Ministry of Health. The Agreement was publishedto develop, implement and evaluate strategies to supportin 2008 and can be found on the NSW Health website:women and to ensure that midwives and doctors have thewww.health.nsw.gov.au/policies/ib/2008/IB2008 012.htmlknowledge and skills necessary to implement this policy.This document describes the rates of pay, hours of work,All NSW Public Health organisations providing maternityon-call arrangements (including documentation of theseservices are required to implement the ten steps providinghours), leave and travel entitlements for midwives whowoman-centred labour and birth care described in thiswork in a MCoC (identified as Caseload Midwifery Practicepolicy directive.in the Agreement) model where they work on an on-callbasis.The Towards Normal Birth policy directive also identifies thechanges to maternity care that are needed:In implementing this agreement, maternity services arerequired to gain approval from their Local Health District Promotion of birth as a natural event for the majority of(LHD) as well as the NSW Nurses Association.women Minimisation of fear, particularly women’s fear, andThe Agreement has been developed in accordance with theimprove support throughout labour and birthPublic Health System Nurses and Midwives (State) Award.Importance of consistent and balanced information forThe Agreement lists a number of clauses from the Awardwomen and health care providers regarding vaginalwhich are affected by the Agreement, and this is importantbirth after caesarean section operation and theto remember when implementing the model, so that it ispotential risks associated with elective caesareanclear when the Award provisions are in place, and whenoperationthe Agreement overrides these. For example, clause 25 ofDevelopment of programs of care, both midwifery andthe Award (Overtime) does not apply to midwives workingmedical, that focus on providing continuity of care.under the Annualised Salary Agreement.Birthrate Plus In accordance with the Award, the Agreement requiresthat LHD’s provide rosters which describe on-call days andBirthrate Plus is a Midwifery Workforce Planningdedicated off-call days. Managers are required to monitormethodology from the United Kingdom (UK). It providesthe working hours of midwives working in MCoC, tomanagers of maternity services with a framework to assessensure that their workloads are reasonable. Midwives inthe required midwifery Full Time Equivalents (FTE) of aMCoC, working with their managers, find many differentservice based upon the needs of women underpinned byways to ensure they have appropriate leave, includingthe standard of one to one care in labour and birth.dedicated days off and adequate annual leave throughoutthe year. Whilst all MCoC’s utilise the Agreement, the wayIn 2011 Birthrate Plus was adopted as the tool forthat midwives work together can look slightly differentassessing the midwifery workforce in NSW maternityfrom one model to another. Agreements between all theservices. It is being implemented across all maternitygroup members and good communication are the keys toservices of sufficient size in NSW, under the direction ofsuccess in implementing the Annualised Salary Agreement.NSW Health. It is a flexible tool which can also be used inExamples of some rosters can be found in Appendix 1.the strategic planning and redesign of services.PAGE 6 NSW HEALTH Midwifery Continuity of Carer Model Tool-Kit

Understanding Midwifery Continuity of CarermodelsWhen developing a MCoC model it is important toperiod. This midwife works in partnership with the woman,understand the definitions and core principles of this way ofidentifying her individual needs and ensuring that she hasworking. The following definitions and core principles canaccess to safe and supportive services. As part of this rolebe applied to suit their local context.the midwife ensures all investigations, consultations andreferrals occur at an appropriate time and collaborates withMCoC models are where midwifery care is provided byother health professionals in accordance with the individualthe same midwife or by a small group of midwives for awoman’s circumstances and health needs.woman. The woman is able to get to know this midwife/small group of midwives throughout an entire pregnancy.The Back-up Midwife (or midwives) is the second pointThis care begins in early pregnancy, continues throughof contact for the woman when her primary midwife is notpregnancy, labour and birth, to the end of the postnatalavailable. This may be due to a variety of reasons includingperiod*.when the primary midwife is not rostered to work, hasworked her maximum clinical hours for that day or is onannual leave, study leave or sick leave.Midwifery Group Practice (MGP) is where a number ofmidwives working in caseload practice organise themselvesinto a group or an agreed working arrangement. There isno ideal number of midwives in a group practice. Midwivesmay organise themselves in partnerships or small groupswithin a larger MGP, or a service may have a number ofsmall MGPs. Regardless of the approach taken, maximisingcontinuity of care should be the underpinning principle. TheDefinitionsgroup will organise and agree their working arrangementsto support one another and to ensure that care is able toCaseload Midwife is a term that describes a midwife whobe provided for caseload women taking into account dayshas an agreed number of women (caseload) per year foroff, annual leave etc.whom she is the primary midwifery caregiver. The caseloadmidwife is the first point of reference/contact for theseAn Annual Caseload is the number of women per yearwomen throughout their pregnancy, labour and birth andfor which a caseload midwife provides primary care. Eachduring their postnatal period. As well as being the primarycaseload midwife is the primary midwife for her ‘own’midwife for an agreed number of women each year,women and provides back up for her midwife partner’seach midwife will also be a second or back up midwifewomen. As stated in the Annualised Salary Agreement thefor women who have another midwife as their primarycaseload of women per year per midwife will be calculatedcaregiver. Midwives working in caseload practice areusing Birthrate Plus , taking into consideration:available over a 24 hour period for an agreed number ofdays/week. The midwife will require a paging and/or mobile Whether the midwife works full time or part timephone system so that the women are able to contact her. The complexity of care required by the woman (e.g.The Primary Midwife is the first point of contact for the medical, psychosocial, co-morbidities)woman through pregnancy, labour and birth and postnatalThe distance travelled by the midwife to provide thiscare* Towards Normal Birth PD2010 045 key measure 3.3 – requires that all women receive midwifery support at home for at least 2 weeks after the baby is born(target 100% by 2015 for metropolitan/regional services; target 80% by 2015 for rural/remote services).Midwifery Continuity of Carer Model Tool-Kit NSW HEALTH PAGE 7

Provision of total or partial postnatal care It is essential that any model being designed is womancentred, sustainable, and meets the needs of the midwivesWhilst the caseload may range between 35 and 42 womenand the service. The following points have been identifiedper year for a midwife working full time it is important toas central to promoting sustainability of a MCoC model:calculate this accurately to ensure the sustainability of theMGP. Core Principles of Midwifery Continuity ofCarer Models The woman and her needs should be central to themodelThe need to maintain professional relationships withwomen, avoiding the development of co-dependencywith the women in their careMidwives have an agreed midwifery philosophy of care, vision for the model and ways of working together managers and obstetriciansThe majority of midwifery care is provided by a primary Regular formal and informal communication is crucialmidwife TransparencyThe primary midwife provides care from early in Flexibilitypregnancy (usually booking visit) through labour and Generosity of spirit between individualsbirth and until two weeks postnatal. Being aware of othersA back up midwife/s is available whom the woman has Trust between and amongst individualsmet on more than one occasion during her pregnancy The developing of a shared philosophy – valuesclarification exercises early on in the development of theOne-to-one care for labour and birth is provided by the MCoC can be usefulprimary or back up midwifeThe primary health care approach facilitates a well Clear reporting lines and escalation processes to line Succession planningmother and baby to transfer home within 4 – 6 hours of birth, with appropriate midwifery support. This mayMidwives have identified key factors for achieving optimalinclude a home visit on the day of birth.work experiences within MCoC models. These are not onlyThe interdisciplinary collaborative approach facilitatesabout successful relationships with the women they caremidwifery care to continue to be provided by thefor, but also the relationships they have with their peers,primary midwife even when complications arisemedical colleagues and managers14:MCOCs utilise the same clinical guidelines, protocols and decision-making frameworks as the rest of the maternity service to ensure consistency and continuityprofessional relationships with women throughof care and best practice. continuity of carerContinuity of midwifery care is valuable and safe for Supportive relationships at work and at homewomen with varying levels of risk in their pregnancy. In Positive working relationships and occupationalfact, women with complex pregnancies may particularlyautonomy involves midwives being able to organisebenefit from receiving continuity of midwifery care.their working lives with maximum flexibility throughMCoCs are well-placed to provide this continuity innegotiation. This includes:collaboration with other health professionals. A model– Positive and supportive relationships with midwiferycan be specifically designed to meet the needs ofpriority groups in the local community (e.g. teenagepregnancies, obese women, women with increasedpsychosocial needs). The ability for midwives to develop meaningfulcolleagues in MCoC model– Collaborative relationships with medical colleaguesand midwifery peers at the hospital– Managers who facilitate professional development,The conclusion of the midwifery relationship is timelyinterpersonal confidence and skills, assistance withand facilitates the woman’s transition into primarydebriefing and reflection.health services (eg. Child and Family Health services andGP)14Leap, N., Dahlen, H., Brodie, P., Tracy, S., & Thorpe, J. (2011). 'Relationships-the glue that holds it together': midwifery continuity of care and sustainability. InL. Davis, R. Daellenbach & M. Kensington (Eds.), Sustainability, Midwifery and Birth. New York: Routledge.PAGE 8 NSW HEALTH Midwifery Continuity of Carer Model Tool-Kit

Understanding the local contextThere are many considerations and challenges in developingand implementing change in maternity care provision. Itis important to understand that all maternity services aredifferent and will require different approaches to developand implement a MCoC model that best suits the needs ofthat service or facility. These changes require collaborationand effective communication between all stakeholders;clinicians (midwives, doctors, nurses and allied health),managers and consumers/community.Each MCoC model will vary as it is influenced by: theneeds of the local women, the community’s expectationsof the service, the role delineation of the facility, who thecollaborating practitioners are and the geography of thecatchment area. The next part of the document discussesthe key steps required to set up a MCoC.Midwifery Continuity of Carer Model Tool-Kit NSW HEALTH PAGE 9

Key StepsThis section includes an overview of the key process stepsProject Planto enable public maternity services to implement MCoC.The timeframe of the development and implementationThe project plan describes the objectives of the project,of the MCoC will vary depending on the needs of theassigns tasks with deadlines, and charts progress inindividual services and the community. The order ofreaching goals and milestones. The project plan needs tothese key steps will also be prioritised differently byinclude:each maternity service and will overlap. Additionally,it is important that a project plan be developed that – Proposed service model– Service Objectives– Key stakeholders and their rolesdemonstrates these key steps and their timeframes.Identify an executive sponsorAn executive sponsor is essential to enable the initial Identification of critical tasks Assignment of tasks (although it may not be possible todevelopment and subsequent implementation of the MCoCmodel. The executive sponsor will be supportive of theassign all tasks at the beginning) Accountability and reporting requirements of projectlead.of the model.Identify a project leaderDevelopment of a time line (a gantt chart may be usefulfor this)model creation and have the authority and influence withintheir role, to promote the development and establishmentDescription of the projectForm a multidisciplinary SteeringGroupThe project leader will lead and manage the day-to-dayrequirements of the project plan. It may be possible thatTo move the project forward it is necessary to establisha current employee of the LHD will be able to undertakea multidisciplinary Steering Group or Working Party. Thisthis position within their current role. However, it may beprocess ensures effective consultation, collaboration andnecessary to appoint to this position for a defined period ofgovernance for the new service.time. The project leader will benefit from:Key stakeholders Passion and enthusiasm for the project Knowledge and understanding of MCoC models andhow they workThese include: Those who influence the current service provision e.g. Being an effective communicator Previous experience in developing a project plan Knowledge of change management Knowledge and understanding of the clinical contextconsultants (CMCs), obstetricians, general practitionersincluding the:(GPs), paediatricians, child and family health nurses and–––––midwifery managers, service managers, hospitalexecutive role delineation of the servicephysical environment of the facilityother members of the multidisciplinary team the community settingthe demographics of the population andthe skill mix and experience of all clinical staff.PAGE 10 NSW HEALTH Midwifery Continuity of Carer Model Tool-KitService providers e.g. midwives, clinical midwiferyThose most affected by the proposed service changee.g. consumers. Any other stakeholders affected by the model e.g.ambulance service if a homebirth service is proposed

Consultation with a diverse range of stakeholders, who areMap the woman’s journeytruly representative, will ensure all views are articulated,heard and considered. It is helpful to include stakeholdersProcess mapping is a great tool to use early in thewho may not be supportive of the model as unresolveddevelopment phase of the MCoC model and will assistissues have the potential to limit the success in the longin identifying every step of the woman’s journey and itsterm. Identifying complex or contentious issues from therelationship to the service. It is also important to include thebeginning enables the solutions to be built into the modelbaby’s journey in this process, so that clear pathways areas it develops. Further stakeholders may be identifieddeveloped and the risk of separation of mother and baby,during the mapping process.should the baby require additional care, is minimized.Local championsIt is useful to map the current journey and then theLocal champions are often already identifiable, due toproposed journey with the MCoC model, to define thetheir individual passion and enthusiasm. This will helpchanges needed to implement the new model of care.to drive the project forward. It is particularly useful tofind a local medical champion. Having champions fromMapping can be done very effectively with a whiteboardmidwifery, obstetrics and/or general practice will not onlyor with post it notes on a large wall. It is a great waybroaden the focus of the meetings but will potentiallyfor people to explore the changes that will need to bepromote collaboration. It is advantageous to engage theseundertaken and engage them in the process.champions as members of the Steering Group as this willoften reinforce the authority of decisions made.NSW Health’s Redesign programme offers learningpackages on redesigning of services and changeSuggested membership of Steering Groupmanagement. In particular, there is a section on processIn identifying membership, It is important to ensure thatmapping which may be helpful for those without previouskey stakeholders and decision-makers are represented. Theexperience.following roles are considered pivotal:The materials can be accessed at: h

Development of programs of care, both midwifery and medical, that focus on providing continuity of care. Birthrate Plus Birthrate Plus is a Midwifery Workforce Planning methodology from the United Kingdom (UK). It provides managers of maternity services with a framework to assess the required midwifery Full Time Equivalents (FTE) of a