Initiative focuses on at-risk pregnant women, moms

Infant mortality rate drops, vaccinations increase

An initiative to improve the health of pregnant women and their infants and toddlers has resulted in a drop in the infant mortality rate for Crozer-Keystone Health System.

When the Crozer-Keystone Healthy Start was begun in 1997, infant mortality and morbidity for African-American infants was 21 infant deaths per thousand in and around Chester, PA. The number has dropped to 14 infant deaths per thousand. The national average is about 6.5 infant deaths per thousand. The Chester area's rate is 10.8 infant deaths per thousand.

As a result of the interventions by community-based case managers, 100% of participants have a medical home, and the immunization rate is greater than 90% for the children in the program.

Crozer-Keystone's Healthy Start program was begun when the hospital received a grant from the federal Bureau of Maternal and Child Health as part of a national initiative to reduce infant mortality and morbidity. The project serves 11 municipalities in and around Chester.

The program provides a variety of free services to pregnant women of any age and families with children younger than 24 months who live in the project service area. The program serves publicly and commercially insured women, women who have no insurance, and those who are undocumented immigrants. There are no income requirements.

"We actively seek out participants through outreach and recruitment. Our staff is out in the street and in the neighborhoods, letting people know about our services. We go anywhere we can to find women and families who are eligible for the program. If we find pregnant girls and women early in the pregnancy, we can have a bigger effect on the outcomes,"says Joanne D. Craig, MS, project director.

More than half of the participants in the program refer themselves after hearing about the program from other participants.

Women who are referred to the program are assessed by a hospital social worker who conducts an extensive assessment at the hospital or her home or place of business. The intake assessment includes a physical and psychosocial assessment, a depression screening, and an education survey. Families are assigned a risk level from 1 to 4. About 85% are level 3 or 4.

Program participants who qualify as high risk are those who are not in school or unemployed, those with an unstable housing situation, patients with chronic mental health or medical problems, who are substance abusers or victims of domestic violence.

"We have a growing population of pregnant girls who are 15 or younger. This automatically qualifies them as a Level 4 risk," says Donovan Pratt, MSW, LSW, case management coordinator.

Community-based care

The case managers who work with the pregnant women are community based and often live in the neighborhoods they serve. As soon as they are assigned a family, they meet with all of the agencies involved with the family and review each agency's role in order to increase efficiency and eliminate duplication of services.

"We work with child protective services, the court system, school systems, mental health providers, and other agencies. We all work together to ensure that the child and the parent will be healthy," Pratt says.

The case managers meet with the families in the community and work to develop a family plan of care that is regularly reviewed and updated and may be completely revised every six months.

They make regular visits and phone calls to the families, depending on the risk level and the needs of the family.

The case managers educate the program participants on factors that could affect the outcome of the pregnancy, such as dietary considerations and stopping smoking. They help the pregnant women get ongoing prenatal care, often picking them up and taking them to and from their doctor visits.

"We take them to the welfare office, take them to the market, and shop with them to pick up the healthiest foods," Pratt says.

If the program participants are homeless, the case managers help them find stable housing. They help arrange treatment for mental illness, substance abuse, or other problems.

If the patient is a pregnant teenager who still is in school, the case managers make sure she keeps going to class. If the woman is a victim of domestic violence, the case manager helps her get to a safe place.

"We're doing more than just working with women related to pregnancy. We look at all the other issues that may have a negative effect on the birth outcome and help the women meet any concern or need they may have. The population we are working with is very vulnerable. Often the pregnancy is the least of what we need to address," Craig says.

The case managers check on the members regularly, by phone or in person, depending on the risk level of the family. Once the baby is delivered, the case manager follows the family until the child is 24 months old.

"We like to see the child through the series of childhood immunizations and well-child visits. In addition, we want the women to have the necessary postpartum visits to the doctor and to take an adequate amount of time to help before they have more children," Craig says.

The case managers provide transportation for the well-child and specialist visits.

"Some of the children go to a specialist 15 or 20 miles away at a children's hospital. It could be an all-day visit," Pratt says.

If a woman gets into the program early on in the pregnancy, she could be in the program for two years. Participation can be longer if she becomes pregnant again by the time her child reaches the cutoff age of 2 years.

When program participants are discharged, the case managers make sure they are connected to community services.

The case managers participate in care conferences with the project's care coordination team. They meet with Craig weekly and review five or six cases to go over problem cases and to get suggestions on managing the care of the family.

The program's case managers meet twice a month at a case management meeting to go over whatever issues they may have and to try to find ways to remedy problems.

"We utilize the experiences of the case managers to see how we can improve on the services we are already providing," she says.

Caseloads

A case manager's typical caseload was 20 to 25 but has recently been decreased to 17 to 20 because of the high acuity of the patients and the intensity of their needs. "Our population tends to be needy, with problems that are compounded and convoluted. The pregnancy is probably the easy part of the equation," Craig says.

The most challenging patients are young teenage girls who have serious mental health issues, such as bipolar disorder and schizoaffective disorder.

"These young women are going through the issues of self-esteem and self-confidence that affect every teenage girl. These girls are pregnant, have a mental disorder, and are in school. They worry about things that other 14-year-olds don't have to face," Craig says.

The case managers help the young women understand their illness, how it can exacerbate throughout the pregnancy, and why it is important that they get treatment.

"Many of the mental health disorders are hereditary, and some of the young women are reluctant to acknowledge that they have the same problems that someone in their family has. The case managers work closely with mental health services to monitor the patients," Pratt says.

A bilingual and bicultural case manager with knowledge of immigration law and community resources manages the undocumented immigrant populations, most of whom are from South America and Central America.

"This is a population where we clearly see a high rate of self-referral. She takes great pains to build a relationship and trust with these women. Many of them decline to move out of the area so they can remain close to her," Craig says.