PRENATAL CARE

Collaborating for Community-Wide Improvement

Many health plans that serve a Medicaid population experience low rates of prenatal care, late initiation of prenatal care, and a high incidence of low-birthweight (LBW) babies. This health plan recognized the risks of death and disability that LBW babies face. Two measures were used to track the impact of cooperation and coordination of education and outreach efforts, and to guide the development of new efforts. Ultimately, the community's health plans implemented a collaborative effort that improved care.

Knowing that pregnancy-related diagnoses fell within its top ten ambulatory encounters and hospitalizations, the plan was naturally concerned with prenatal care. Concerns about prenatal care were heightened by baseline measurements conducted in 1993. Of more than 2,000 births, almost 15% were LBW. In that same year, the plan noted that although more than 90% of its pregnant members received some sort of prenatal care, less than 50% received it in the first trimester.

The plan could see the opportunity and need for improvement. It established a multidisciplinary task force to improve access to early prenatal care.

The plan used two related measures to monitor progress:

• Prenatal care during the first trimester
• LBW babies (less than 2,500 grams)

In addition, the plan measured the percentage of women who had received no prenatal care during their pregnancy.

Since 1993, the plan has audited medical records on all deliveries. Baseline measurements performed in 1993 showed 2,254 live births: 8.3% of women had no prenatal care at all, only 45.2% received care in the first trimester, and 15% of all pregnancies resulted in a LBW infant.

The plan's staff identified two benchmarks for the incidence of LBW babies. The regional Medicaid norm was 14%, while the norm for commercial managed care organizations was <5%. The plan did not identify a benchmark for first-trimester prenatal care.

Using Healthy People 2000 goals and the regional norms, the task force chose two goals:

• A first-trimester prenatal care rate >90%
• A LBW rate <9%

Faced with limited resources, the task force began by tapping into several programs that were already underway. Health education and home care efforts were strengthened and coordinated.

In addition to pregnant women, new mothers were targeted in order to impact care received in future pregnancies.

The plan's health education program focused on member literature. Visiting nurses and hospital home care departments developed and distributed a perinatal care package. Women also received a written guide after their first OB visit.

The plan contracted with a lay home visiting program. Volunteers referred pregnant mothers to their primary care physicians (PCPs) for early prenatal care.

COMMUNITY PROGRAMS The primary challenge to ensuring access to first-trimester prenatal care is early identification. While improvement can be made with plan-wide efforts, early identification is best enhanced by a community-wide effort. Collecting and analyzing data on a community-wide basis may lead to the most significant improvements in prenatal care.

In 1994, the plan took the following actions to improve access and medical management:

• adopted self-referral to OBs
• gave all OB providers a list of services and tests that could be performed without a referral
• required OB practitioners to complete and return a risk-assessment form for each patient
• added a lead removal program s a pilot project; this program gave mothers the opportunity to have their homes assessed for lead levels and thoroughly cleaned if needed; it was designed to enhance the current outreach efforts focused on this same target population
• had health educators visit a number of schools to provide education on pregnancy

During 1994, the plan reported 1,960 births. Of these, 7.5% received no prenatal care, 45.6% received prenatal care during the first trimester, and 14.4% qualified as LBW. It appeared that the plan's educational and early identification efforts were not enough to significantly affect performance. The plan took the following additional actions during 1995:

• Fully implemented the lead removal program
• Had a maternal/infant case manager contact all pregnant women and their obstetricians to evaluate risk
• Had a maternal/infant case manager follow all high-risk members throughout pregnancy
• Contracted with a mobile unit staffed with two advocates. This colorful van traveled throughout the community to identify pregnant members, encourage access to prenatal care, distribute educational materials, and facilitate prenatal visits. It focused on high-visibility venues such as health fairs, schools, recreational centers, county offices, and frequently visited intersections.
• Conducted in-service training for advocates and lay home visitors.
• Revised the member OB guide, ensuring clarity and an appropriate reading level.

The 1995 data showed significant improvement on two measures: the percentage of members who did not receive any prenatal care (from 7.5% to 5.3%) and the percentage of members who received care in the first trimester (from 45.6% to 50.1%). However, the LBW rate remained in the 14% range.

In 1996, the task force performed a barrier analysis using a member survey of all women who did not receive care in the first trimester.

Women surveyed identified many barriers that prevented them from seeking first-trimester care and managing their pregnancies, including:

• Transportation
• Babysitting
• Financial constraints
• HIV/AIDS
• Complex medical problems
• Abusive relationships
• Drugs and alcohol

The results of this survey led the plan to devote significant resources to two new interventions. First, it established a special needs unit composed of four case managers - a maternal/infant manager, a social worker, an HIV/AIDS manager, and a complex case manager. This unit addressed the psychosocial and clinical issues preventing women from seeking care or managing their pregnancy. Second, it linked the completion and submission of the risk-assessment form to each obstetrician's payment.

During 1996, the plan reported 1,772 births, 5.6% of which did not receive any prenatal care. Of those births who received prenatal care, 55.4% were conducted during the first trimester, a significant increase over the previous year. The LBW rate remained essentially unchanged. For the first time, the plan was able to break out the rate of very-low-birthweight (VLBW) babies, at 3.1%.

In 1997, the state mandated that all Medicaid recipients choose a health plan. This mandate removed the fee-for-service option for Medicaid patients. Three additional health plans were contracted to serve the Medicaid population. Members were allowed to switch plans on a monthly basis. Month-to-month eligibility concerns made it difficult for all the plans to identify, educate, and manage a member's high-risk pregnancy.

Because each of the plans serving the Medicaid population struggled with the same issues, they united to establish a collaborative program. This program had three main features:

• Member education
• A common risk-assessment form
• High-risk care management

The plans established a shared database for tracking members. It contained information on member demographics, first-trimester care visits, risk-assessment score, delivery date, outcomes data, and other factors.

The plans also instituted quarterly prenatal postcard reminders and mailed preventive care information to members.

HMO SWITCHING Quality improvement efforts can be particularly challenging in the Medicaid population. Month-to-month changes in eligibility and HMO switching may mean that the best (or even only) way to track members is to create partnerships with others.

The plan continued to track the performance of rates in 1997 for first-trimester prenatal care and no prenatal care which were 54.7% and 7% respectively.

This profile shows how hard-to-reach populations, like those in this 100% Medicaid HMO, are best served with creative thinking and collaborative efforts. In working with three other health plans, this plan was able to meet the particular needs of its special community. Measures in 1998 showed a decrease in the rate of LBW infants.

Although the improvements seen in the chosen measures are modest, the process knowledge gained, the partnerships forged, and the attention given to fundamental barriers represent a solid foundation for future efforts aimed at this very important target population. This plan and its competitors have collaborated to address their common challenges of member identification, outreach, and early access.