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Programs follow moms through pregnancy, NICU
Case management is program's strongest component
Two programs at Passport Health Plan help pregnant Medicaid recipients overcome the obstacles to a healthy pregnancy and follow preterm infants through the neonatal intensive care unit and back home.
Passport Health Plan is a Medicaid health plan, serving 140,000 people in 16 counties in the Louisville, KY, area. The plan is sponsored by the University of Louisville, local hospitals, and traditional safety net providers. AmeriHealth Mercy Health Plan of Philadelphia administers its programs.
The Mommy and Me Program aims to improve the prenatal care and infant and maternal health of members. The Tiny Tots Transition Program helps promote a smooth transition to home for newborns with serious health conditions, according to Theresa Watson, RN, BSN, manager of health management for the health plan.
The health plan also partners with community agencies to sponsor events to promote healthy pregnancies.
Passport Health Plan stratifies the approximately 7,000 pregnant women it serves each year into three risk levels. Depending on their level of risk, members' care during the pregnancy is managed by a non-clinical outreach staff member or a nurse case manager.
Women eligible for the program are identified when their physician offices contact the plan to get global authorization for prenatal services, through community agencies, and by self-referral. New members, who become eligible for Medicaid by becoming pregnant, are identified through their new member information form.
Three risk levels
Members who fall into Level 1 are at low risk and receive a basic education packet and a book about healthy pregnancies and what to expect. A Passport outreach staff member calls the Level 1 members, conducts a basic assessment, and educates them about community resources, such as the Women Infants and Children's program (WIC). They educate the women on the importance of making regular visits to their physician and attending prenatal classes.
"If there are any indications that the woman is having any difficulties with her pregnancy, she is referred to a nurse," Watson says.
Members who have some medical problems that may interfere with the pregnancy, such as urinary tract infections, anemia, uncontrolled asthma, and chronic hypertension are stratified to Level 2 and are monitored by a nurse case manager. Young women who will be younger than 15 when they give birth also are placed on Level 2.
Level 2S members smoke but otherwise have few risk factors. They receive outreach calls from a non-clinician who directs them to a smoking cessation program.
Members at highest risk are those who have had a previous poor birth outcome or who have one or more risk factors for possible poor outcomes for mother or baby. They are stratified to Level 3 and receive intensive monitoring and assistance from nurse case managers.
Level 1 and Level 2S members typically receive an initial phone call when they are enrolled in the program and another between 20 and 24 weeks, during which the outreach staff member educates them on what to expect during the delivery. The nurse or outreach staff member will discuss symptoms of preterm labor, which may occur at that point in pregnancy.
Level 2 and Level 3 members receive regular telephone calls throughout their pregnancy, depending on their needs.
When appropriate, the Passport nurse case managers may go with the members to doctors appointments or send a home health nurse into the home if they need follow-up care, such as blood pressure monitoring.
When a woman has been hospitalized before delivery, the case manager may refer her to the local departments of health in Kentucky for follow-up education in the home. Health department personnel will address warning signs of early labor or recommend a special diet for women with severe hypermesis (uncontrolled vomiting).
"Our nurses work with the members' physicians to ensure that the pregnant women get everything they need. The nurses we have on staff cannot provide the medical care but we join forces with home health agencies or the department of health to assist with the clinical piece," says Helen Homberger, RN, director medical management and Early Periodic Screening, Diagnosis, and Treatment (EPSDT).
Members in levels 2 and 3 receive phone calls at least once a month and can call the nurse directly if they have a problem or call the health plan's 24-7 nurse plan if it's after business hours.
"In the beginning, these members may need telephone follow-up as frequently as twice a week. When they call into the 24-7 nurse line, their case manager is alerted so she can follow up," Watson says.
CMs monitor babies in the NICU
When infants end up in the neonatal ICU, their care is managed by two hospital-based Tiny Tot Transition program nurse case managers, who work with the hospital NICU staff and case managers to ensure a smooth transition to home.
The nurses are assigned to Norton Kosair Children's Hospital in Louisville, where the majority of babies are treated. Each of the nurses also is assigned one other hospital with a Level 3 neonatal intensive care unit.
"It's a hybrid program. The nurses do both utilization management and case management. They are in the hospital, monitoring the baby's progress every day, reviewing the records, and working with the family as they progress toward discharge," Homberger says.
Case management is the strongest component of the program, she adds.
"When we studied the length of stay for our NICU population, we did a chart review and determined that it was critical to engage the baby's caregiver in the educational process early in the admission. What we thought would be a utilization program became a care coordination model," Homberger says.
The case managers actively work to get the caregivers into the facility and train on how to take care of the tiny infants. They work with the family, calling in community agencies when needed, to ensure that the family has everything they need for a safe discharge, including a place to live, water, and electricity.
"These mothers have a lot of barriers to overcome. They have transportation issues, other children in the home, and many of them work and don't get paid if they take time off to come to the hospital. We work through those barriers to help them come to the hospital and learn to take care of the infant when they are home," Watson says.
The case managers address the mothers' concerns, help them get the supplies they need such as baby beds, make sure they have the durable medical equipment they will need to monitor and care for the baby at home. They help with enrollment in WIC and other programs that can assist them.
Choosing a primary care provider
"We work with them to pick a primary care provider for their infant and set a follow-up appointment before the baby is discharged. We monitor whether or not they kept the appointment and if they didn't set up another appointment for them. We'd like for them to have a follow-up visit within a week after discharge," Watson says.
About 97% of the members in the program reach the health plan's goal of having their infant seen by a primary care physician no more than 30 days after discharge. The other 3% took their baby for a follow-up visit but it was after 30 days.
Through the Tiny Tots program, Passport Health Plan has reduced readmission rates for these tiny babies by 30%, from a 10% readmission rate in 2001 to a 7% readmission rate in 2006.
"One of the things we have not been able to impact with the program is the rate of emergency room visits. This is an understandable factor with tiny babies and first-time moms. They're dealing with a new situation and a child on multiple types of equipment and medications. Although the ER visits haven't decreased, they have remained stable," Homberger says.
Passport Health Plan has collaborated with community agencies to sponsor regular events to educate pregnant women on how to have a healthy pregnancy.
The plan sponsors monthly "baby showers" at county community mental health centers in collaboration with the Seven Counties Community Mental Health System and the Kentucky Department of Health. The parties, funded in part by Kentucky's tobacco settlement money, include lunch, gifts for the moms, and an educational segment on tobacco use.
The Mother's Day Out program, held at a larger venue in collaboration with the Department of Health, includes lunch, gifts, fun activities, a massage therapist, a manicurist, and a speaker who educates the women about drugs and alcohol. The program also addresses domestic violence and EPSDT for children.
"The program is open to any women served by these agencies. Not all of the women who attend the programs are Passport Health Plan members. However, our goal is to support healthy pregnancies throughout the community. We are aware an adverse event during pregnancy can result in an adverse birth outcome and an infant may need multiple medical services for many years. These infants may be our future members and we want to promote health pregnancies and healthy babies," Homberger says.