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Case managers reduce pre-term deliveries
Nurses provide support, hormone injections
A program that provides face-to-face case management and hormone injection services for women at risk for pre-term birth has reduced the spontaneous pre-term birth rate by 8% among the Medicaid population served by the program.
Nurse case managers with obstetrical experience visit at-risk women in their home once a week during the last half of pregnancy providing education, support, and administration of injections of 17 alpha-hydroxy progesterone (17P), a hormone that keeps the uterus from contracting during pregnancy. Women in the program have had previous pre-term births, putting them at risk for another early delivery, says Jean Schmitz, BSN, RNC, CDE, CCE, West Region Area clinical director for Alere Health, a health management services business with headquarters in Atlanta.
"Pre-term births are very costly and are on the rise in this country. We estimate this program saves payers an average of $6,000 per pregnancy," Schmitz says. "About 99.5% of women in the 17P administration program complete it. We believe that the support the nurses give these women is as important as giving the injection and providing improved access to care."
Patients are referred to the program through their obstetrician. Many insurers, including Medicaid, cover the injections. A large portion of the patients in the pre-term labor program are Medicaid beneficiaries. However, Schmitz points out, "pre-term labor affects women of all races and socio-economic levels."
"The populations of people who have the most difficult time accessing quality medical care are those who receive Medicaid benefits. Many pregnant women on Medicaid haven't had exposure to routine medical care, and they often have barriers to receiving care like transportation issues," she says.
The company manages a national network of obstetrical nurses who go to the patients' homes once a week to provide nursing services. Nurses from the company's clinical operations center make regular calls to the patients in between face-to-face visits. "This is a nationally based program with the benefit of having nurses in the participant's community to go into the homes," Schmitz says. The community-based nurses share information with nurses in the company's clinical operations center who also have access to patient information when they talk to them.
When women are referred to the program, an obstetrical nurse case manager reviews the clinical information to determine if the women meet criteria for the program. The nurse case managers help them understand that their physician has indicated that they are at risk for a premature birth, and they schedule an appointment at the home. (For what the nurses do during each visit, see story below).
The clinical operations center nurses make outbound calls to the patients between visits to assess how they are doing and intervene using the treatment plan from the patient's physician. For example, if the woman is at risk for pre-term labor and is hypertensive, the nurse follows the doctor's guidelines on how to manage the problem.
The nurses in the clinical operations center are RNs with labor and delivery experience. The company operates clinical operations centers throughout the company and has a large center that takes after-hours calls. The nurses at the clinical operations centers have access to all patient data, the physician orders, and the patient chart, which allows them to provide seamless assistance to the patients regardless of when patients call.
The company operates similar programs for women with chronic hypertension, gestational diabetes, severe nausea and vomiting, and other conditions that put them at risk for a premature birth.
Nurses help with more than just the pregnancy
In-home visit is key to success
When the nurse case managers in the high risk pregnancy program at Alere Health visit mothers-to-be in their homes, they do more than just provide hormone injections and educate women about pre-term labor. They also help the family with other needs.
"Our program is not just providing an administration nursing service. It is a system of care coordination and support. People will participate in their care if someone shows that they care about them. We are doing this by bringing this service into the home of Medicaid beneficiaries," says Jean Schmitz, BSN, RNC, CDE, CCE, West Region Area clinical director of Alere Health, a health management services business with headquarters in Atlanta.
"When nurses visit women in their homes, they often can assess at a glance what their needs may be," Schmitz says. If the family can't pay the rent or the electric bill, they work with local churches and social service agencies to provide assistance. "We see situations all the time where people need help. Because our nurses live in the community, they know the resources available to help. If not, they reach out to the physician's office, the hospital, or social service agencies in the area. We are showing the moms that we care in helping them understand the resources that are available to them and their families," she says.
When the nurse case manager visits, she assesses the home situation, performs a maternal and fetal assessment, and starts the educational process about the signs and symptoms of pre-term labor. For example, women might experience dull pain in the lower back or tired legs. They feel like something isn't right, but they don't realize the symptoms indicate labor until they experience a true contraction. "We teach the women in the program to recognize the signs and symptoms of premature labor early on rather than waiting until they experience the pain of a true contraction. At that point, it's more difficult to stop the labor," Schmitz says.
On each visit, the nurses administer injections of 17 alpha-hydroxy progesterone (17P), a hormone that keeps the uterus from contracting during pregnancy, and they review the signs and symptoms of premature labor. "The mothers have the phone number of a nurse they can contact 24/7. They don't have to wait until their doctor's appointment if they sense that they are having problems," Schmitz says.
The nurse remains in the home for 30 minutes after the injection to make sure the woman doesn't have an adverse reaction to the medication. She makes sure the woman has a telephone number to reach a nurse 24 hours a day.
The case managers go over educational materials geared to the woman's needs, such as information on diabetes, hypertension, smoking cessation, and alcohol use. They educate the mothers-to-be on how to stay healthy during pregnancy, the importance of good nutrition and fluid intake, and exercises to keep her healthy. They discuss what to expect during pregnancy, show the woman pictures of what is going on with the baby at each point in the pregnancy, and explain any medical terms the mother might hear from her physician.
A large group of the women in the program do not have telephone service. In those cases, Alere has the telephone installed and pays for service through the delivery so the participant can call if she has questions or concerns.
The nurses visit the mothers at least once a week to provide the administration nursing service, including the P17 injection and continue educating them about signs and symptoms to watch for. They work closely with the patients' physicians, follow the physician's treatment plan, and keep the physician informed about what is happening with the patient.
"We look on ourselves as an extension of the physician's office in helping manage patients with complications of pregnancy," Schmitz says. "We offer home-based solutions when the doctor doesn't have any other option but to put the woman in the hospital."