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Home visits help members avoid preterm births
Program saves $2.80 for every $1 spent
A combination of telephonic case management and home visits has helped Optima Health decrease preterm births and low-birth-weight infants.
Optima Health estimates that it has saved $2.80 for every dollar spent on its award-winning Partners in Pregnancy program and has avoided nearly 3,000 days in the neonatal intensive care unit since the program began in 2002.
Optima Health, the health plan division of Norfolk, VA-based Sentara Healthcare, established the program to promote healthy pregnancies and reduce premature births for both its Medicaid and commercially insured populations.
The high-risk population includes both Medicaid and commercial members, often for different reasons, says Karen Bray, PhD, RN, CDE, vice president, clinical care services.
"The Medicaid members often have financial and social issues. In our area, we have a renowned in vitro fertilization program and we are managing the care of a number of older women in the commercial population who are carrying multiple babies," she adds.
The health plan partners with Virginia's Comprehensive Health Investment Project (CHIP) to conduct home visits to assess the needs of hard-to-reach members and to follow them through the pregnancy if needed.
'We rarely miss a pregnancy'
The majority of members in the program are identified when their physicians send in authorization forms for obstetrical services. Members can self refer or physicians can directly refer them. In addition, the health plan scans its claims database regularly to identify members who have had positive pregnancy tests.
"We rarely miss a pregnancy," Bray says.
As soon as the plan identifies a member who is pregnant, the information is automatically transmitted to the Partners in Pregnancy team.
Women who are likely to be at risk for problems during the pregnancy, such as very young women, older women, and women with a history of problems in pregnancy automatically are assigned to a case manager who calls them and conducts a detailed risk assessment over the telephone.
Low-risk pregnant members are assigned to patient service coordinators, who contact the member, conduct the risk assessment, and determine whether the woman should be referred to a case manager.
The patient service coordinators and case managers make monthly telephone calls to the women throughout the pregnancy, talking to them about how things are going, and conduct serial risk assessments to screen the members for problems with the pregnancy.
"The patient service coordinators and case managers can increase the frequency of the telephone calls if the members request it or if they feel the member would benefit," Bray says.
When the case managers or patient service coordinator can't get in touch with a pregnant woman who lives in an area with a high incidence of low-birth-weight babies, Optima calls on its community partner, CHIP, to locate the members and conduct a risk assessment.
If the member is at high risk for complications of pregnancy, CHIP continues to provide home visits by nurses and other outreach workers, if appropriate.
Contracting with home health
In areas where there are no CHIP programs, Optima contracts with home health agencies to provide specific services.
The case managers can also call on CHIP if they have concerns about the situation in a pregnant member's home.
"In these cases, the case manager feels that a more thorough evaluation of the home situation may help to determine the risk level," she says.
CHIP lay workers and nurses who visit the home evaluate the home condition, family's financial and social issues, and the stress level of the mother-to-be.
"We know that stress seems to be a factor in low-birth-weight infants. Some of these members are at risk of losing their home or have terrible family problems. We get them in touch with community social services and have gone so far as to intercede with landlords who were trying to evict a family," Bray says.
CHIP services include transporting women to medical appointments, connecting them with substance abuse programs, teaching them how to care for their infants, and connecting them to social services agencies that can provide assistance. The case managers follow the members throughout their pregnancy, making sure they receive the standards of care, such as regularly seeing the physician. They help the women manage any complications or comorbidities, such as gestational diabetes or hypertension, and educate them about community services that are available if appropriate.
For instance, poor dental health can adversely affect a pregnancy.
"Many women don't realize that the condition of their teeth can affect their baby. We send them toothbrushes and toothpaste and refer them to a dental provider if needed," she says.
The health plan sends out regular packets to the mothers with information about pregnancy and a small gift. For instance, the stress management packet includes information about how to deal with stress and a bottle of lotion.
T-shirts, water bottles, diaper bags, and a book about baby's milestones are other gifts that the members receive as long as they are in the program and talk regularly to the case manager or patient service coordinators.
The Partners in Pregnancy program has won numerous awards including a national award from the Disease Management Association of America.