CHECK-UPS AFTER DELIVERY

Improving Program Participation

The eight weeks after giving birth are a period of physical, emotional and social changes for the mother. During this period she is also adjusting to caring for her new baby. In order to give clinicians who care for new mothers the chance to offer advice and assistance, the American College of Obstetricians and Gynecologists recommends that women see their health care providers at least once between four and six weeks after giving birth. The first postpartum visit should include a physical evaluation, and an opportunity for the health care provider to answer parents' questions and give family planning guidance, as well as advice on nutrition. [1]

As early as 1992, this plan had instituted educational programs for expectant and new mothers. Although these services were regarded as successful, they failed to reach all interested members.

The rate of check-ups after a delivery was important to the plan because it was a HEDIS measure, and it reflected plan efforts to encourage preventive health, as well as to ensure the continuity and coordination of care.

The plan decided to explore improving the participation rate in its existing programs in order to increase the number of women who received recommended postpartum care.

The plan used HEDIS specifications, including changes as they occurred, to identify the population and to calculate its performance measure. It employed hybrid methodology using encounter/claims and medical record data. No sampling was used for baseline determinations; the entire population was included in the measure.

The plan targeted all women with live births during the reporting year. In 1996, it included all women who were continuously enrolled for 42 days after delivery. In subsequent years it included women who were continuously enrolled for 56 days after delivery.

The performance measure in 1996 was the percentage of the target population with a postpartum visit by the 42nd day after delivery. This was modified in subsequent years to the percentage of women in the target population with a postpartum visit between 21 and 56 days after delivery.

Baseline performance, based on 1996 data, showed that 63.3 percent of new mothers had a check-up within six weeks after birth. The 1996 median rate for all plans within the corporation was 64.48 percent for HMOs, and 61.9 percent for POS plans. This plan used these rates as its benchmarks. No goal was identified.

The plan used a multidisciplinary HEDIS task force to compare performance with other plans in the same corporation, and with benchmarks. Staff from quality management, utilization management, marketing, provider relations and the medical director were on this task force. It reviewed possible barriers, which were then presented to a physician advisory committee for feedback and approval. The task force considered information about OB/GYN accessibility and availability, along with member demographics.

The initial barriers identified included:

• The physician is called out of the office, and the woman's postpartum visit is rescheduled outside the accepted time frame
• Women do not schedule postpartum appointments if they are feeling fine
• Physician offices do not have a tracking system for ensuring women are seen for postpartum check-ups

The plan communicated to providers the importance of postpartum check-ups in its provider newsletter. It reminded them to notify the precertification department, so that women may be offered participation in expectant and new mother outreach programs.

The plan developed its own expectant mother outreach program, administered by a contracted vendor. The vendor contacted all expectant women on a list provided by the health plan. Women who chose to participate received a minimum of three telephone assessments during pregnancy. Women identified as high risk during these assessments received additional contacts. The program provided educational materials about pregnancy, nutrition and infant care. It provided answers to specific concerns raised by participants.

The new mother outreach program was offered to all women who were participating in the expectant mother outreach program. These women received a visit prior to delivery, and two after. In addition, the new mother outreach program was offered after delivery to women who did not participate in the expectant mother program. Contracted hospital maternity units assisted in giving information about the program to women who had just delivered. As part of this program, women were advised about the need for postpartum care and are urged to make an appointment within the appropriate time frame.

CONTRACTED VENDORS The plan noted the importance of spending sufficient time with its vendor, and emphasized the importance of clear contracts and expectations. Plan staff point out that it is important to share the reasons for initiating the programs. Reports from the vendor about the differences between mothers who chose to participate and those who didn't were valuable in increasing participation rates. Staying in close contact is critical; if you find out about problems too late, there is no chance to take corrective action. There is no substitute for a qualified and experienced vendor that is willing to submit reports in a detailed electronic format.

The plan encouraged participation in these programs with newsletter articles, consultation with OB/GYN practices and meetings with the vendor. It stressed the importance of these programs for women with an early release from the hospital following an uncomplicated delivery.

The plan also offered incentives to obstetricians and PCPs to see women for postpartum visits.

The first remeasurement, based on 1997 data on a sample of 411 women, showed that 78.7 percent of new mothers received a postpartum check-up between three and eight weeks following delivery (weighted average rate for both HMO and POS). While the time frame changed, this was a significant improvement.

The plan continued to attack the barriers identified earlier. The plan included a calendar sticker in its expectant mothers outreach program. This helped remind women of the need for a postpartum visit.

INVOLVING CLINICIANS The prenatal assessments from the outreach program were sent to the women's obstetricians. The obstetricians appreciated this information. It helped remind them of the need to include information about postpartum visits in their charts. Some practitioners implemented office-based tracking and reminder systems as a result of this activity.

A postpartum check-up measure was added as a performance monitor within the global OB/GYN contract. Monetary thresholds were established for low performance (below a particular rate) and for high performance (above a particular rate).

The second remeasurement, based on 1998 data from a sample of 411 women, showed a rate of check-ups after delivery of 82.2 percent. This was an increase over the previous year, as well as compared with the baseline rate of 1996.

The plan has continued all education and outreach programs. The key lessons learned are applicable to any quality improvement activity: obtain physician support, use a multidisciplinary group to determine the direction for interventions, and consider the use of financial incentives and disincentives.

[1] - National Committee for Quality Assurance, HEDIS 2000 vol. 1 (Washington, D.C.: National Committee for Quality Assurance, 2000), 42.