Program reduces pre-term, low-birth-weight babies
Program reduces pre-term, low-birth-weight babies
Program combines education, personal outreach
Since implementing a maternity program that includes educational mailings and telephone counseling sessions for all pregnant members, BlueChoice HealthPlan of South Carolina has been well below the state average for pre-delivery hospitalizations and pre-term deliveries. And health plan members have experienced a drop in pre-term admissions and neonatal intensive care unit (NICU) lengths of stay.
BlueChoice HealthPlan of South Carolina is a wholly owned subsidiary of BlueCross Blue Shield of South Carolina.
The Great Expectations maternity program was established in 1990 and has been augmented and refined in subsequent years, according to Laura Long, MD, MPH, chief medical officer and vice president of health services at BlueChoice HealthPlan.
"We are consistently below the Southeastern average for premature births. South Carolina has a high incidence of preterm labor and NICU days. We have been well below the state average on both measures over the last decade and our birth weights are consistently heavier," Long says.
The health plan scores in the 90th percentile on HEDIS measures related to pregnancy and is NCQA accredited at the excellent level. More than 90% of members who fill out a member satisfaction survey after delivering a baby rate the program's materials extremely useful, very useful, or useful.
From 2004 to 2007, antepartum admissions dropped from 5.5 per 1,000 to 4.9 per 1,000 and premature births dropped from 5.4 per 1,000 to four per 1,000.
"Providing education to members gives them a sense of control and an awareness of signs and symptoms of any problems that may occur. We keep the lines of communication open between the members and our nurses as well as their physicians," she says.
The Great Expectations maternity care management program provides educational mailings and telephone counseling sessions with nurses for all members, along with disease management and case management for high-risk members.
An adjunct to the maternity care management program is a postpartum depression and screening program.
Members are stratified as to their risk of complications through medical history, claims data, and a risk-assessment questionnaire mailed to all pregnant members, along with a packet of educational materials and care guidelines. Women can complete the questionnaire over the telephone or fill it out and mail it back.
When members choose to actively enroll in the program, they can opt to receive regular mailings in addition to telephone calls from pregnancy counselors, who make outreach calls once a trimester to pregnant women at low risk for complications.
During the counseling call, the nurses discuss diet, exercise, the member's support system, and whatever issues are appropriate for the stage of pregnancy.
They review pre-term labor signs and symptoms of other problems that may occur, such as hypertension.
"We try to reach them after the ultrasound so we can discuss any issues that arose," says Marie Fox, manager of the maternity program.
The health plan's counselors include two RNs and an LPN as well as two RNs who handle case management and utilization review for high-risk members.
All of the nurses have backgrounds in labor and delivery and are familiar with the types of complications and other problems that pregnant women develop, Fox adds.
High-risk maternity patients may have gestational diabetes, high blood pressure, depression, or severe hyperemesis. Their care is coordinated by RN or LPN disease managers who support them through the pregnancy, helping them understand their conditions and comply with their treatment plans.
Complex high-risk members who qualify for maternity case management have very high risks for complications and frequently need multiple services from multiple specialists.
For instance, they may be being treated by specialists for a neurological disorder such as multiple sclerosis, cardiac problems, or severe diabetes. Some have been hospitalized for pre-delivery complications or are on bed rest and receiving home health services.
"The case managers handle the most complex of the high-risk patients. They provide 360-degree support as often as necessary. They coordinate with multiple physicians to obtain precertification for services; help the members obtain any medications they need and arrange for them to be delivered to the home if necessary; provide psycho-social support, bringing in social workers as necessary; and provide the kind of education that the members would receive from a traditional disease management program," Long says.
When a pregnant member is hospitalized, a case manager calls within seven days of discharge and determines how often the patient needs follow-up.
"The case manager facilitates communication between the obstetrician and the specialist and makes sure the patient gets the referrals she needs. If the patient needs home care or durable medical equipment, the case manager makes sure it arrives on time," Long says.
Many of the women referred to case management are on bed rest. In these cases, the case manager helps provide the support the patient needs, such as referring her to disability resources, helping her fill out the Family Medical Leave Act (FMLA) paperwork, or helping her link to a church or other community groups.
If the fetus has a congenital abnormality that will make it a special needs child, the case manager helps the mother connect with support groups ahead of time.
The case managers who work with complex maternity patients also handle utilization management for their patients, making it easy for obstetrician offices to refer members for disease management and obtain precertification for services at the same time.
"Our maternity program is a one-stop shop, with the utilization management and disease management in one place. This means that our obstetrician offices have to interact with only one group of nurses. This allows our nurses to form a relationship with the obstetricians and their office staff, resulting in better coordination of care for the member," Long says.
Dealing with postpartum depression
The postpartum depression program sends information to pregnant women about the symptoms of postpartum depression and how to recognize them, along with a symptom assessment scale they are to complete and take to their physician.
Physicians in the plan receive peer-written educational materials stressing the importance of asking women about postpartum depression and a symptom assessment scale they can use to diagnose the condition in their members.
"One in 10 women has postpartum depression. It's an often unrecognized problem. We want to raise awareness about the problem with the physician community. We want to make our members aware postpartum depression is a problem that is treatable and direct them into treatment," Long says.
When Blue Choice HealthPlan's maternity counselors call members who are pregnant, they screen them for postpartum depression. The health plan provides information to members on support groups as well as information about how to obtain a mental health professional referral.
In addition, case managers who work with high-risk members complete a depression screening each time they call the member. If the response is positive, the case manager refers the members for mental health counseling within their benefit coverage.
"Women who are experiencing a stressful or complicated pregnancy are at higher risk of developing depression during or after pregnancy. Women facing a high-risk pregnancy, especially those on bed rest, may be more susceptible to depression," Fox says.
Before starting the program, the health plan surveyed its pregnant members and new mothers and asked if they had received any written information about postpartum depression. About 30% of respondents to the baseline survey reported they had information about the condition. After the program began, the response rate rose to 70%-80%.
In response to whether a medical professional had talked to them about postpartum depression, 31% responded affirmatively during the baseline survey. In a recent survey, 57% of those responding reported talking about the condition with a medical professional.
"There has been a substantial improvement in awareness of the problem among our members and the medical professionals," Fox says.
The maternity program is one of a number of BlueChoice Health Plan's Great Expectations for health programs. The health plan also offers Great Expectations programs in diabetes, children's health, asthma, chronic obstructive pulmonary disease, depression, heart disease, heart failure, men's health, women's health, migraine, weight loss, and smoking cessation.Since implementing a maternity program that includes educational mailings and telephone counseling sessions for all pregnant members, BlueChoice HealthPlan of South Carolina has been well below the state average for pre-delivery hospitalizations and pre-term deliveries. And health plan members have experienced a drop in pre-term admissions and neonatal intensive care unit (NICU) lengths of stay.
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