The maternal mortality rate in the United States has risen in the past 20 years, even as rates in other affluent nations are decreasing. The United States also has one of the highest infant mortality rates among high-resource countries.
• Maternity case managers can help patients achieve the goals of a healthy pregnancy, healthy baby, and healthy mom.
• Red flags for high-risk pregnancies include gestational diabetes, addiction problems, and other health and behavioral health issues.
• Case managers screen patients for depression and provide them with support, including a baby shower with educational materials and small gifts.
American women who are pregnant or have just given birth are dying at a rate higher than most high-resource nations, and the morbidity rate is three to four times greater for black women. Their death rate is equivalent to pregnant women in less affluent nations, including Mexico or Uzbekistan. (For more information, please visit: https://bit.ly/2TUh38x.)
Ten-year data from the Centers for Medicare & Medicaid Services (CMS) show that pregnancy-related deaths are highest for black women, followed by Native American/Alaska native women. Hispanic women experience the lowest maternal mortality rate. (More information can be found at: http://bit.ly/38jx6Sw.)
Maternity case managers can help prevent pregnant women from experiencing health crises and help keep their infants out of the neonatal ICU (NICU). Case management helps promote better education about the risks of preterm births. (See story on preventing maternal and infant mortality and morbidity in this issue.)
“Maternity case managers are RN case managers who focus on education and support for pregnant women during pregnancy and the postpartum period,” says Sandy Coleman, MSN, RN, CCM, manager of integrated care management with Partners in Pregnancy at Optima Health in Virginia Beach, VA. “The goal is a healthy pregnancy, healthy baby, and healthy mom at the end. We help reduce mortality and morbidity among moms and babies.”
The U.S. also has the highest infant mortality rate among high-resource nations. Healthcare organizations must focus on what can be done to reverse this trend. There is a big push for more resources and case management of pregnant women, Coleman says.
“We’ve had our maternity case management program since 2003, but this type of program has become more popular in the news,” she explains. “More people are aware of it, and as the initiatives grow, we’ve become more successful at it.”
From a health payer’s perspective, maternity case management can save costs by preventing preterm births and long NICU stays, says Susan Hines, RN, BSN, RN-BC, manager of clinical care services at Optima Health. “The long-term effects of a NICU baby include intellectual disabilities, hearing loss, blindness, cerebral palsy — lifelong effects for these babies,” she explains. “It’s advantageous to have case managers work with moms to make sure they’re getting prenatal care and have access to nutritious food and other things necessary to make sure they carry their babies to term.”
Help Patients Understand Risks
Case management nurses working in the prenatal care setting can help women understand their potential risks for preterm labor and birth, and to advise them on the steps they need to take to minimize that risk, Hines says. These steps include proper nutrition, exercise, and stress reduction.
There will always be health crises that result in preterm babies and maternal health complications, but interventions can help, Hines notes. “We want to intervene where we can and make a difference where we can, so moms are healthy and can deliver healthy babies,” she says.
All pregnant women in the health plan are eligible for the case management program, Coleman says. They can refer themselves or their provider can refer them. Once they are enrolled, clients receive support and outreach.
“Our goal is to get 100% enrolled. We reach out to as many as we can and try to focus on those higher-risk pregnancies,” Coleman explains. “Women with chronic conditions or [negative] socioeconomic factors are linked with appropriate resources to meet their social and medical needs, nutritional needs, and to make sure there’s a support system in place.”
Case managers reach out to women who have had a premature birth or are at high risk of a preterm birth. Red flags for high risk could include diabetes, gestational diabetes, addiction problems, and other health and behavioral health issues, Hines says.
“We recommend to those moms to be part of our prenatal program,” Hines says. “We have one-on-one conversations monthly, or however frequently that is appropriate, with those moms.”
Case management is extremely important for pregnant patients, as well as for any person with a health condition that requires more resources, Hines says. “The difficult part is engaging these members and getting them to commit to speaking with a nurse on some kind of consistent basis and to learn from our nurses,” she explains.
When case managers cannot reach a person by phone, they will send a letter, asking the member to call if they are interested in the prenatal program, Hines says. “We’re also looking at using emails and text messages to reach high-risk members,” she adds.
Once case managers receive a referral, they call the member to explain the program’s goals and to complete a comprehensive assessment. “We develop a care plan and schedule follow-up,” Coleman adds. “We coordinate any services she might need, and refer her to any community resources.”
Case managers ensure patients have transportation to their doctor’s visits, and that there are no nutritional gaps. “We give them education based on where they are in the pregnancy,” Coleman says. “We answer questions about birth control and proper birth spacing, and we talk about breastfeeding, making sure they understand their options for feeding their babies.”
They also educate women on preterm labor, high blood pressure symptoms, signs and symptoms of problems, and how to report their concerns to providers and feel empowered to speak up, she says.
Case managers give patients online resources and send them customized mailings. “We assess them and stratify them in high-, medium-, and low-risk categories,” Coleman says. “We follow them at intervals based on that risk — every two to three weeks, depending on their risk level.”
Enrollees and providers can call case management through an 800 number between their scheduled calls, and whenever they need information or help.
“We follow them throughout the pregnancy, postpartum trimester, and for six to eight weeks after pregnancy, which we call the fourth trimester because it’s equally as important as the other three,” Coleman says. “So many things can happen in the postpartum period.”
Each patient has one case manager who works with her throughout the pregnancy and postpartum period. Sometimes, the same case manager will be available to work with her for her second or third pregnancy, Coleman says.
The case manager’s reward is hearing that the mother and baby are doing well after case management ends, she says. “Sometimes, we get pictures of the baby, and they are really thankful for our services,” Coleman says. “We get that reward at the end when things go well.”
When patients have chronic conditions like diabetes, high blood pressure, or sickle cell anemia, they are referred to a community-based team to make sure they receive long-term resources, she adds.
Case managers also screen every patient for depression several times throughout the pregnancy. They refer members to counseling services and lactation support, including breastfeeding classes and hospital-grade breast pumps, as needed. Also, there is a network of resources to support pregnant members. These include education, food pantries, diaper banks, churches, and nonmedical organizations.
“We have a program where we offer baby showers to members, giving them a little education while they have fun,” Coleman says. “They can bring a family member or support person with them to the baby shower.” These range from small to large showers with 10 to 15 pregnant attendees. The organization’s outreach department provides them with snacks and small gifts.
If a pregnant woman experiences housing challenges, case managers can help her access local housing resources, including finding her financial assistance through the community.
When infants are born preterm and spend time in the NICU, maternity case managers will help the mother with whatever she needs, making sure the women are taking care of themselves, Coleman says.
“It’s the same care coordination and case management we do when the baby is born full term, but we look at different routes to get them through the NICU period,” she explains. “We try to stay with them until the baby is discharged.”
Each case management connection is individualized. “There is not a cookie-cutter answer,” Coleman says.
Case managers help members access all the full benefits from Medicaid or other payers. “We make sure they’re maximizing those benefits,” Coleman explains. “If they have trouble filling a prescription, we work with them to get that filled. If they need help paying for things, we reach out to community partners.”
Case managers also contact physicians and others to educate them about the program and to coordinate education for patients about prenatal care, Hines says. “We make sure we’re all on the same page and telling members the same thing,” she adds.
The maternity case management program works well, helping a population that needs additional support, Coleman says. “People don’t realize that a normal, complication-free pregnancy and delivery are not the norm,” she says. “More often than not, there’s at least one complication, roadblock, or barrier, and that’s what we’re here to walk women through.”
Pregnant women so often feel lost, confused, or think they have done something wrong when their pregnancy is not picture-perfect, Coleman notes. “We do everything we can to make sure the women and their babies are healthy,” she says.