PREGNANCY MANAGEMENT

Pursuing Better Care During Pregnancy

This health plan considered both demographics and the causes of hospital admissions when deciding what activities to pursue. Women of childbearing age accounted for a large and influential segment of its membership. Obstetric admissions were the most frequent type of hospitalization among this plan's commercial members. The plan initiated improvement activities aimed at care delivered throughout the prenatal and postpartum periods. Guided by a small number of related HEDIS measures, the group has maintained a focus on continual improvement of pregnancy management.

The plan had analyzed its claims and reinsurance data from 1992. It noted a high incidence of neonatal intensive care unit (NICU) days. These NICU days were not only of financial importance but also indicated a poor pregnancy outcome. Recent studies have demonstrated that early prenatal care can improve the outcome of pregnancy and reduce the incident of low-birthweight (LBW) babies.

Improving maternal and infant services became an important priority for this plan. It decided to implement a healthy pregnancy program.

The plan used HEDIS 2.0 (and as they were released, 2.5 and 3.0) methodology. A panel of measures related to pregnancy management was selected:

• Prenatal care in the first trimester
• Cesarean section rates
• Vaginal birth after caesarean (VBAC) rates
• Low-birthweight (LBW) rates
• Very-low-birthweight (VLBW) rates

In 1997, a HEDIS 3.0 measure of postpartum visits was added. The plan collected 1993 base-line data on these indicators of maternal health. The plan used the goals of the US Preventative Health Services Task Force to establish its own benchmarks and to set its performance goals (see PARAMETERS for each measure).

From these initial data, the health plan concluded that it was providing early care to most of its pregnant women. The vast majority of pregnancies had positive outcomes. Timely, thorough, and effective prenatal care had detected and addressed maternal health problems early in pregnancy and limited the number of LBW babies. The plan's challenge was to extend good pregnancy management to an even greater proportion of its members.

The plan's staff defined good prenatal care as including four main activities:

• Encouraging healthy lifestyle habits
• Identifying and assisting individual women with special risks
• Helping women to understand their options
• Answering the questions and concerns of members

This plan's staff felt that they had to provide continuous messages of encouragement and make good prenatal care easily accessible. In January 1994, the plan contracted with an external organization to administer a healthy pregnancy program. The program was designed to support the practitioners' management of prenatal care. It focused on risk assessment and maternal education.

The program monitored, implemented, and evaluated interventions in complicated pregnancies. It provided education and information for uncomplicated pregnancies. Practitioners referred their patients to the program. Self-referrals were also encouraged.

The healthy pregnancy program had several goals:

• Maximize participation by promoting options of self-referral and practitioner referral
• Screen all pregnant members via a telephone health-risk assessment
• Provide general prenatal and risk-specific education through brochures and other materials
• Educate members about the signs and symptoms of preterm labor
• Proactively facilitate case management intervention in high-risk cases
• Promote compliance by encouraging members to communicate with their practitioner
• Provide a 24-hour telephone line for advice and support from a nurse educator

Realizing the importance of communication to its providers and members, the plan kept everyone informed of its activities. In spring 1994, it published an article about the pregnancy program in its member newsletter. Plan staff members, OB/GYN providers from the network, and managed care office staff attended an educational forum on maternal health.

The result of these interventions was a slight but significant increase in the rate of first-trimester prenatal care. However, the plan felt that it was on the right track and that repeated interventions would reach a larger number of members.

The plan identified a need to continue efforts aimed at increasing the number of women receiving prenatal care in the first trimester. It conducted an analysis that revealed barriers to prenatal care, including:

• Lack of member awareness about the importance of early prenatal care
• Lack of physician and medical group endorsement of the healthy pregnancy program
• Needed improvements in the referral process for the program

In 1995, the plan implemented three main interventions:

• The member newsletter featured a story about a member's experience with a complicated birth; it showcased the case management component of the healthy pregnancy program
• The educational forum was repeated and publicized via wellness brochures and articles in the member and practitioner newsletters
• Data were shared with medical groups; these data heightened the awareness that not all members received prenatal care in the first trimester; the data helped each medical group develop strategies for how to improve.

As a result of the 1995 interventions, the rate of prenatal care in the first trimester increased to 84.9%, a statistically significant increase from the 1993 rate of 80.7%. C-section rates remained unchanged, and the VBAC rate rose from 27.8% in 1993 to 37.8% in 1995. The 1995 results for LBW and VLBW babies were similar to the 1993 baseline measurements. Recognizing that high rates of LBW babies were not a significant problem for its membership, the plan ceased collecting data on LBW and VLBW rates after 1995.

In 1996, the plan continued its efforts to improve pregnancy care. A multidisciplinary process improvement team was formed to evaluate the effectiveness of the healthy pregnancy program. The referral process and the management of high-risk cases were of particular concern.

In order to evaluate the effectiveness of the healthy pregnancy program, the team worked with the external vendor to compare the outcomes of those members who participated in the program in 1995 with those who did not. Medical records were abstracted from 410 randomly selected members who were enrolled with the health plan at the time of delivery, had single/multiple live births or stillborn fetus(es), and had a 20-week or greater gestation.

Data elements collected included demographic information, date of first prenatal visit, delivery type and date, birth outcome, and birth weight. These data were compared with the results from 402 program participants who completed a telephone survey during the same reporting period.

The comparison revealed that the proportion of healthy pregnancy program participants who received prenatal care in the first trimester was nearly 15% higher than for nonparticipants. In addition, the VBAC rate among participants was 7.3% higher than for nonparticipants. There were no other major differences.

CONSTANCY OF PURPOSE The plan's staff learned that any quality initiative needs constant attention and maintenance. Activities need to be constantly reviewed for effectiveness. Even a simple project can have meaningful impact if a group builds on its previous experiences and success.

HEDIS 3.0 data collected for 1996 showed an increase in the rate of first-trimester prenatal care to 87.1%, a statistically significant increase over the 1993 baseline data. C-section and VBAC rates remained steady.

When faced with a small gain in 1996, the plan established a process improvement team to study the barriers to improvement and to suggest new or revised interventions. The team worked with graduate students from a state university who helped them address the problem. They scientifically and systematically evaluated the steps already taken.

This team's efforts revealed three major barriers:

• Medical group dissatisfaction with the referral process to the healthy pregnancy program
• Lack of incentives for member participation
• Lack of physician involvement in or awareness of the program

In 1997, the plan made numerous additions and changes to its interventions designed to overcome these barriers.

An online policies and procedures manual was developed to help member service representatives answer questions about the healthy pregnancy program, identify members who might be interested in the program, and capture data necessary to refer members to the program vendor.

The plan developed outreach tools to encourage early enrollment in the program. One such incentive was a magnetic photo frame. It contained messages about compliance with regularly scheduled prenatal visits, well-baby immunizations, and enrolling babies within 31 days of delivery.

Other interventions included:

• Education for health plan and medical group staff
• A toll-free phone line for practitioners requesting program information
• Targeting the population by using the pharmacy database to identify prescriptions for prenatal vitamins
• A telephone survey to determine the appointment availability of OB practitioners
• Refinements in case management procedures to enhance communication between staff and clinicians
• Continued communication about the program in member and practitioner newsletters
• Distribution of prevention health practice guidelines that included information on prenatal care

The results of the 1997 intervention were disappointing - the rate of prenatal care in the first trimester appeared to drop from 87.1% in 1996 to 81.7% in 1997. Some of the decrease was believed to be related to a change in methodology with HEDIS 3.0. (The necessary period of continuous enrollment was reduced, possibly capturing more members in the midst of some transition of care.)

VBAC rates did not change from 1995 to 1997, but they rose by ten percentage points from 1993 to 1997. C-section rates decreased four percentage points from 1993 to 1997.

The plan began to track postpartum visits (a HEDIS measure) in 1996, starting from a baseline measure of 53.1%. This indicator increased 25 percentage points from 1996 to 1997, and the plan is now in the process of establishing a goal for the postpartum-visit measure.

Since formally concluding this initiative, the plan has continued to collect data. Twelve interventions were scheduled for 1998, many of which are continuations of previously implemented interventions.

Two important new activities are being instituted through the risk assessment provided in the healthy pregnancy program. First, program participants who smoke or have asthma are being referred to the plan's smoking cessation and asthma management programs. Second, the health plan is selecting a new vendor for the program based on feedback from OB/GYNs who advise the process improvement team. The new vendor is to provide educational materials and counseling services.

This initiative shows that staying the course is difficult but worthwhile. With disappointing results in 1997, increasing vendor costs (currently $165 per participant), and labor-intensive activities such as verification of the pharmacy data, some would suggest dropping the prenatal program. However, instead of abandoning the initiative, the plan is taking new steps to increase program participation in 1999. (An outline of the program for 1999 is included in Appendix 15.) It is considering partnering with some of its medical groups to make good prenatal care a shared responsibility. Although the details of this program are still in the works, the plan's long track record of focusing on important projects, establishing a systematic approach, and evaluating results suggests that these new interventions will be successful.