INITIATION OF PRENATAL CARE

Outreach at Open Enrollment

Early, high quality prenatal care is a critical component in ensuring a good pregnancy outcome. Although it's ideal for women to begin prenatal care during the first trimester, some women enroll in a health plan at a later stage of pregnancy. This health plan realized the need to initiate prenatal care as soon as possible in these cases.

According to the Centers for Disease Control and Prevention, between 1970 and 1980 there was a significant upward trend in the percentage of women who began prenatal care in the first trimester. Since 1980, however, that trend has hit a plateau. Even more troubling is the trend of women waiting until the third trimester to begin prenatal care. [1]

Health-plan-specific data indicated that initiating prenatal care at the time of enrollment was an important issue. A largely commercial plan with a high female membership, the plan noted that 52 percent of its enrollment was female, and 57 percent of the female membership was of childbearing age. With a membership turnover rate of 10.6 percent per year, the plan embarked on a baseline assessment looking at the percentage of recent enrollees initiating prenatal care within six weeks of enrollment.

The plan used HEDIS 3.0 specifications to target women who had live births during the reporting period, and had been enrolled in the plan for more than six weeks, but less than 44 weeks prior to delivery. The performance measure was the number of women in this population who initiated prenatal care within six weeks of enrollment.

Using hybrid data collection from 1996, claims and medical record data were used to calculate a baseline rate of 68.7 percent. No sampling was used; data were collected on the entire targeted population of 351 women.

The plan compared its results to the 56 plans reporting these data in the 1996 edition of NCQA's Quality Compass. A benchmark of 84.5 percent was established, based on the nationwide 90th percentile rate. The plan then set a one-year goal of an 80 percent rate (by 1997), and a two-year goal of 85 percent (by 1998).

A number of groups examined the baseline data. A subcommittee of the Quality Improvement Committee, a multidisciplinary physician advisory group, and a QI subsidiary of the corporate parent organization explored possible barriers to new members receiving prenatal care soon after enrollment. The consensus? The lack of member knowledge of the importance of prenatal care was the most important barrier.

Another possible barrier was the need for a new member to first select a PCP, and then obtain a referral from that PCP to an OB/GYN.

A maternity outreach program had been established in spring of the baseline year. It featured regular nurse contacts. The plan distributed program materials, such as an expectant mother diary, prenatal care and breast-feeding guides, and growth charts as incentives to participants.

OUTREACH AT ENROLLMENT With the maternity program already underway, the plan explored ways to increase its effectiveness, particularly among newly enrolled women. The answer? The plan engaged its sales and marketing staff, who provided information on prenatal programs at marketing presentations to employees, and at open enrollment meetings. In this way, new enrollees received educational materials at, or even before, the time of enrollment.

Providers were informed of the maternity outreach program at quarterly joint operations meetings between the plan and participating medical groups. Both providers and members were informed of the program with a series of newsletter articles.

The plan also eliminated the referral requirement for obstetrical care.

The first remeasurement, based on 1997 data, documented that 77 percent of women in the target population had initiated prenatal care in the first six weeks with the plan. This represented a statistically significant improvement, but the plan was still short of its first year goal.

The subcommittee of the Quality Improvement Committee that was managing the activity embarked on further barrier analysis. It used a fishbone diagram to discuss potential root causes for the lack of timely prenatal care among newly enrolled pregnant women (Figure 1).

The plan intensified its focus on awareness and education.

It made its maternity outreach program more comprehensive. Maternity phone support was made available around the clock, with more intense nurse case management assisting throughout pregnancy with services such as the coordination of referrals. Comprehensive materials included a risk assessment questionnaire and a discount catalog of baby care items. The plan continued to rely on its sales/marketing group to promote the program at open enrollment.

Member newsletter articles highlighted the outreach program, as well as open access to an obstetrician after a positive pregnancy test.

Network practitioners were informed of the enhanced maternity program through a series of breakfast and lunch meetings.

SPECIALTY-SPECIFIC SUPPORT With a considerable investment in a comprehensive maternity outreach program, the plan realized the need to engage clinicians. One method was the use of an advisory panel of practicing physicians. Recognizing the unique health care needs of its female population, the plan hired a full-time medical director for women's health. This individual, a board certified OBIGYN, headed a department assigned to facilitate women's health issues.

The second remeasurement, based on a systematic sample of the population, and using 1998 data, showed a rate of timely initiation of prenatal care of 88.9 percent. This represented a statistically significant improvement over the previous year. The plan had exceeded its 1998 goal and the initial benchmark.

The health plan continued its efforts during 1999. It continued to promote its outreach program to members and practitioners. It involved the pharmacy department. Members identified as having filled a prescription for prenatal vitamins were sent letters informing them of the outreach program and the importance of prenatal care. The plan has conducted more intensive analyses to identify barriers, set a new performance goal and examined new interventions most likely to further improve the rate of early initiation of prenatal care.

[1] - Department of Health and Human Services, Healthy People 2000 (Washington, D.C.: Department of Health and Human Services, 1990), 381.