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Aggressive outreach and intervention deliver major dividends regarding at-risk pregnant women

Pregnancy-related care is a huge cost driver for most Medicaid healthcare organizations. High-risk deliveries are particularly expensive, especially considering the cascade of costs that goes along with admission to the neonatal intensive care unit (NICU). Policymakers know that early intervention can go a long way toward preventing birth complications, but making that happen in a transient, disadvantaged population is no easy task.

It’s a problem the Monroe Plan for Medical Care, based in Rochester, NY, decided to take on, beginning in late 1997. Since then, the health plan has put together a multipronged approach that has not only gotten huge numbers of providers to participate, but also has made a major dent in the health plan’s NICU costs.

Quality improvement efforts

Working with the Hamilton, NJ–based Center for Health Care Strategies (CHCS), a nonprofit organization focused on improving healthcare quality for Medicaid recipients, Monroe started by developing a way to better identify pregnant women early on; the plan made it mandatory for providers to fill out and return a prenatal registration form for any pregnant woman they treated.

“We paid our providers $30 for the submission of this form, and the ‘stick’ that we used was a potential denial of reimbursement for prenatal care if it was not submitted,” says Joseph Stankaitis, MD, MPH, chief medical officer at the Monroe Plan for Medical Care, who spoke at a March 21 audioconference sponsored by CHCS that focused on care-management strategies for high-risk asthma and high-risk pregnancy.

The threat of denied reimbursement boosted submission rates of the forms from 3% to greater than 90%, but in many cases, the submission was too late, with the health plan receiving the forms a week or two before delivery. “You really have to know who is pregnant early enough in order to intervene for those who are at high risk,” Stankaitis says. “It really doesn’t help if you find out that someone was pregnant . . . by receiving the claim for the delivery. There is very little you can do to affect the outcome.”

To try to get the forms filled out earlier, health plan administrators held face-to-face meetings with the providers and their staff members to explain the purpose behind the prenatal registration forms. They also implemented a tiered reimbursement process whereby providers who submitted the forms in the first trimester would receive $50 per form, those who submitted in the second trimester would receive $30 per form, and those who submitted in the third trimester would receive $20 per form. This plan, which started in 2001 and remains in effect today, has kept first trimester form submission rates well over 60%, he notes.

In addition to ramping up its efforts to identify pregnant women earlier, the Monroe Plan also took steps to improve the stratification process that categorizes pregnant women into different risk groups. This helped bring attention to some behavioral health issues that were falling through the cracks. There was no coordination “between the prenatal staff and the behavioral health staff in terms of addressing issues that had to do with mental health or chemical dependency problems that were identified on [the prenatal] forms,” Stankaitis says. To address this problem, the health plan formalized a process requiring both behavioral health and medical staff members to review all prenatal registration forms.

Psychosocial issues take a toll

With identification and stratification processes in place, the Monroe Plan turned its attention to outreach and intervention. “What we found from our own birth-outcomes database was . . . a high correlation of poor birth outcomes with women who are socially isolated, have unstable home environments, or experience spousal abuse,” Stankaitis says. As a result, the plan added a social worker to its staff and implemented a social outreach program specifically focused on working with women who face these types of psychosocial issues.

Fortunately, the health plan administrators at Monroe didn’t have to start from scratch with their program. The type of approach they had in mind already existed in the Rochester, NY, region in the form of a grant-fund program offered through Strong Memorial Hospital’s social work division. Called Baby Love, the program reaches out to women through social workers and paraprofessionals, or nonclinicians who then identify areas of need and link the women with resources and support. Monroe contracted with Baby Love to provide outreach services to women identified as having significant psychosocial risks.

“It is a home visiting program, so we will go to them, and the initial visit will be with a social worker and an outreach worker,” says Kelly Petzing, LMSW, a supervisor with the Baby Love program. “The social worker does a full psychosocial assessment and then comes up with a plan for whatever we might be able to do to help.”

That aid might be something as seemingly simple as driving the women to their medical appointments. For women who have no source of transportation, it’s a huge help. Additionally, the health plan has learned that the travel time shared by the outreach worker and the client can be particularly productive.

“What the outreach folks do is allow the individuals to really talk about issues that they probably wouldn’t talk to their providers about,” says Stankaitis, who referred to this space and time in the vehicle as a “safe zone.”

“A lot of things get uncovered, and there are incredible moments in terms of finding out what is going on, and also teachable moments, too, in terms of enhancing what is the right thing to do in terms of care. Having that connect—engaging the patient—that is where it is all at.”

In addition to providing transportation, outreach workers might assist the women in obtaining food, clothing, baby supplies, or any other basic items they may need. The social worker also may provide referrals for substance-abuse treatment or other types of specialty care. “Pretty much anything that might be identified as an issue for the family we will try to address, and then we stay involved throughout the pregnancy,” Petzing says. “The outreach worker will do regular visits, usually about every two weeks or so, just to continue building that relationship and working on whatever is identified as a need for that family.”

Pilot program shows promise

Typically, Baby Love will stay involved with the family long enough to do a postpartum visit, and conduct a final assessment to determine any additional needs that require attention. “We want to make sure the mom has her postpartum visit and that the baby has the first couple of pediatric visits, and then we will refer the family on to other programs if there are ongoing needs,” Petzing says.

Program administrators always attempt to pair clients with outreach workers who have similar cultural or community ties. For example, Spanish-speaking outreach workers are available to work with women of Hispanic heritage.

And Baby Love piloted a program with the Monroe Plan in which pregnant African-American teens were paired with African-American women who had previously been pregnant teens themselves, and who had overcome the obstacles involved. “They really served as tremendous role models and offered a vision of hope for some of these girls . . . and it really worked well,” says Stankaitis.

Approach delivers improved outcomes

Since the Monroe Plan’s quality improvement efforts began in 1997, there has been gradual improvement in NICU admission rates per 1,000 births. But the most dramatic reduction in NICU admissions—a drop of more than 30 NICU admissions per 1,000 births—occurred in 2003, one year after implementation of the Baby Love outreach program.

“Clearly, we think that has made a huge difference for us and is probably the major driver for our outcomes here,” Stankaitis says.

There also has been a difference in terms of dollars. He points out that the effort has delivered an ROI of $2.52, meaning that for every dollar the health plan has spent on the intervention, it has saved more than $2.50.

In reviewing the health plan’s success, Stankaitis underscores the value of working with community-based organizations and services. “Don’t try to duplicate existing services. It doesn’t make any sense to do that,” he says. “We tried to do some of our own social outreach early on . . . but really, if you have someone in your community already doing this, and they’ve got a lot of experience and know how to manage the system better than you can, don’t duplicate it. Work with them.”