Stepping Up to Step 10 at Trinity Health Ann Arbor

“Isn’t that amazing? It’s one of my favorite things to talk about.”

That’s how Nancy Dmitruchina, MSN, RN, IBCLC, expresses her enthusiasm for the Breastfeeding Medicine practice at Trinity Health Ann Arbor in Michigan. The practice is their innovative yet practical answer to Step 10 of the Ten Steps to Successful Breastfeeding.

Step 10 calls for facilities to “coordinate discharge so that parents and their infants have timely access to ongoing support and care.” Many facilities fulfill this guidance by providing the patient a list of outpatient resources or offering access to an electronic app at discharge. But the folks at Trinity Health Ann Arbor, in partnership with the Trinity Health IHA Medical Group, have taken a much more proactive approach for patients who live in the community and desire an in-person follow up with an IHA provider. They’ve set up an outpatient practice specifically to support breastfeeding mothers after discharge.

Care Continuum

Dmitruchina can barely contain her excitement when she talks about it. She is the Baby-Friendly Coordinator for the hospital, and also works in the  Breastfeeding Medicine practice.

“We look at it as a care continuum,” she says. “We’re able to prepare mothers who plan to breastfeed before they have their baby, support breastfeeding during the hospital stay, and then keep supporting her until the end of her breastfeeding journey, however long that is for her.”

The practice was the brainchild of pediatrician Lisa Hammer, MD, IBCLC. She founded the practice in 2016, shortly after she came to Trinity Health IHA Medical Group.

“When I first came here, there wasn’t really any place for moms to get the kind of care we now provide,” reflects Dr. Hammer. “Once you start doing this work and you start seeing these families, you realize how much need there is for this. We’re busy all day, every day. I don’t think there’s enough awareness about how many families struggle with this.”

Viable Model

The practice is open Monday through Friday and is staffed by Dr. Hammer and Nancy Dmitruchina, along with Kathryn Lankton, DO, IBCLC; Emily Piniatoglou, CNP, IBCLC; Kelly Strickler, CNP, IBCLC; Elizabeth Hoskins, LPN, IBCLC; Anglea Welton, MA, LPC, IBCLC; and receptionist Phyllis Newman.

Dr. Hammer says the biggest challenge at the outset was creating a financially viable model of care..

“We needed to figure out a way to bill for this service so it could be self-sustaining,” she recalls.

Dr. Hammer worked with Blue Cross and Blue Shield of Michigan to rewrite some of the lactation billing codes and gained agreement that she could bill the visits as office visits and be covered by insurance. With that hurdle addressed, she and her colleagues worked to integrate the outpatient care with the care provided in the hospital.

“What’s so great is how the hospital and the practice help each other in supporting the Ten Steps,” says Dmitruchina. “It’s really important to look at how all the steps lead to each other and how they need to be reinforced after discharge.”

Because Dmitruchina works in both places, she hears feedback from patients at all stages in the continuum and can bring that feedback to both the hospital and the practice to continuously improve care.

Integrated Medical Plan

The key, says Dr. Hammer, is being able to care for both mom and baby through an integrated medical plan.

“The reality is breastfeeding can sometimes be extremely complicated physiologically and medically. We have two patients who are very fragile and vulnerable,” she says. “We develop a medical plan to help both mom and baby  reach their goals ― and all of that is communicated to both the pediatrician’s office and the OB’s office to keep all care informed and the mom doesn’t receive mixed messages from different providers.”

Then the staff continues to follow up with the family to provide support.

“Sometimes we can get them to exclusively breastfeed, sometimes pumping and bottle feeding is their best outcome, and sometimes we help them transition to formula if breastfeeding is not medically going to be in the cards for them,” says Dr. Hammer. “Whatever the best strategy is for them, we help them through that journey.”

One Mother’s Journey

Amanda Borg offers a real-life example of how this support benefits patients. She and her husband, Josh, welcomed their first child, Evelynn, into the world on August 22, 2023. With a degree in public health, Amanda was committed to breastfeeding, but it proved to be challenging from the get-go.

“Right away, something wasn’t right,” she recalls. “We were having trouble getting her on the breast and she kept pulling away. We were told she had a shallow latch and I already had pretty significant nipple trauma, two days in.”

When they got home, Amanda continued to try to breastfeed despite the discomfort, but grew increasingly concerned that Evelynn was not getting enough milk.

“She was so sleepy,” Amanda says. “We would wake her up and do all the things we read about – take her clothes off, wake her up, change her diaper mid-feed – but she was not really showing tons of hunger cues. I wasn’t even sure she was getting any milk.”

Then the first visit to the pediatrician raised concerns about Evelynn’s weight loss. Shortly after, Amanda became feverish and noticed a lump in her breast – both signs of mastitis.

“By that point, she was waking up and wanted food,” she says. “But it hurt so much.”

That’s when Amanda was referred to the Breastfeeding Medicine practice Dr. Hammer confirmed the mastitis, gave her topical treatment for severe nipple trauma, and prescribed antibiotics. The staff also worked with her on a plan to “triple feed” Evelynn ― breastfeed, then pump, and then bottle feed the pumped milk ― to ensure she was getting enough calories.

“They started us on this journey of learning,” Amanda says. “It turns out my daughter has a high palate and her tongue muscles lack coordination, and those things make it difficult for her to latch and pull milk from the breast and also from a bottle.”

The clinic referred them to occupational therapy to strengthen Evelynn’s tongue and work on her feeding mechanisms. In the meantime, after following the triple feeding regimen for a week, Amanda decided to pump and bottle feed exclusively.

“It was emotionally a lot, knowing she really wasn’t getting anything from me, and I was still recovering from the mastitis,” she says.

Now a month and a half since the birth, Amanda can look back and fully appreciate the support she received.

“It’s been a difficult journey,” she reflects. “But they’ve been so encouraging and patient-centered and they’ve helped us make decisions that are best for our family. Without them, it would have been much, much worse. I think it should be the standard of care for supporting new mothers everywhere.”

“We Love Step 10”

Amanda’s story is music to Dmitruchina’s ears. “We are all so proud to share the work that we are doing,” she says. “We love Step 10 and are dedicating our hearts to this mission!”