Redesigned prenatal program takes off

New marketing boosts enrollment 400%

The prenatal program at First Priority Health had been limping along and moved between departments for more than three years. It wasn’t until First Priority, a subsidiary of Blue Cross of Northeastern Pennsylvania in Wilkes-Barre, moved the program to the care management department and gave it a whole new look that enrollment soared from 100 women for all of 1996 to nearly 400 women in the first eight months since the program’s redesign.

"First Priority had a prenatal program, but it wasn’t impacting the prenatal population," says Anne Sehne, RN, BSN, CCM, manager of care management at First Priority. "It was redesigned to take the holistic approach of care management. We set a goal to revamp the program and reintroduced it in April 1997 with a new marketing strategy. The formula is working."

The first change First Priority implemented was a fresh approach to marketing the program to both members and physicians. "The difficulty with the prenatal program is that it’s voluntary. Now, the first communication pregnant members receive from us is a letter welcoming them to the program," says Sehne. "The program is voluntary, but we don’t tell them that initially. We welcome them to the program, outline all the benefits available at no cost to the member, and by the time they finish reading the letter, they want to take advantage of those benefits."

First Priority also made a stronger pitch for the prenatal program to the plan’s primary care physicians. "We reintroduced the program to many of the physicians’ offices and presented the program to them in person. We had one physician who was still a little resistant until his nurse got pregnant and entered the program," says Joy Hack, RN, BSN, CCE, prenatal coordinator for First Priority.

Like many prenatal programs, First Priority begins by identifying pregnant members and evaluating them for risks which could cause complications such as preterm labor. "We receive a list of every member who has had a global referral for pregnancy in the previous month. We contact the physician’s office by mail to confirm each pregnancy," says Sehne. "Once we confirm the pregnancy, the member is sent a risk assessment, the welcome letter, and a brochure explaining the program."

Completed risk assessments are returned to Hack who identifies risk factors and places members in one of three risk categories: low risk, potential risk, or high risk.

"Any member considered potential or high risk has a summary report sent to them and to their physician. We just state that we’ve identified the following concerns from the returned questionnaire. Of course, we also cover those at risk during telephone contact with the member," says Hack.

All enrolled members receive the same educational resources targeted to their gestational age, notes Hack. (See list of information sent to members, above.) In addition, Hack contacts high-risk members as soon as their risk factors are identified. "I go over the risks with them and touch base with them at least once a month. Other members receive a call at 28 weeks to discuss topics relevant to their gestational age," she says.

To make each telephone contact more uniform, Hack developed teaching guides which she uses during each member contact. "I used to touch on different prenatal health issues without any specific guidelines," says Hack. "Now, we have specific tools that outline the material to be covered during each call. It reminds me what to cover, and if I’m out and a member calls in, another staff member can pick up the teaching guides and fill-in for me."

In addition to the literature, the risk assessment, and the telephone counseling, the program offers members discounts for childbirth, prenatal exercise, breast-feeding, and parenting classes. "Offering discounts on the classes is another subtle way to nudge members into taking more responsibility for their own health. It tells them what they should be doing to take care of themselves and their baby," says Sehne. "For example, many women don’t know that they could be exercising. By offering discounted rates on prenatal exercise classes, we’re encouraging moms to participate."

Postpartum visits

The program also includes a postpartum home health visit for mom and baby. "We had always provided a postpartum visit, but we had used whatever home health agency was available with no specific criteria or documentation to tell us what these agencies were doing for our members," says Sehne. "When we revamped the program, we first developed credentialing criteria for the home health agencies. Then we developed specific criteria and guidelines for the agencies to follow including postpartum teaching guides," she says. In addition, First Priority requires agencies to fill out a sheet listing any concerns women raise during their postpartum home health visit. "One week after the home health visit, the agencies follow up with a telephone call to each of our moms to go over the guidelines again and find out if any new concerns need to be addressed."

[For more information, contact the following:

Anne Sehne, RN, BSN, CCM, manager of care management; Joy Hack, RN, BSN, CCE, prenatal coordinator, First Priority Health, P.O. Box 3500, Wilkes-Barre, PA 18773. Telephone: (800) 822-8753.]

Pedersen AT, Lidegaard O, et al. Hormone replacement therapy and risk of non-fatal stroke. Lancet 1997; 350:1,277-1,283.

Estrogen and combined estrogen-progestagen replacement therapy in women over 45 neither increases nor decreases the risk of thromboembolic or hemorrhagic stroke, according to a study published in the Nov. 1, 1997, issue of The Lancet.

It has long been accepted that estrogen-replacement therapy in post-menopausal women can have a protective effect against coronary heart disease, but "the effect of HRT [hormone replacement therapy] on the risk of stroke remains controversial," according to the study’s authors. They add that "there are few data on the influence of combined HRT regimens and on subtypes of stroke."

To test the possible effects of HRT on stroke risk, the researchers from the department of obstetrics and gynecology at the University of Copenhagen in Denmark used the Danish National Patient Register to identify all Danish women ages 45-64 who had suffered a non-fatal stroke between 1990 and 1992. Each of the women was then mailed a questionnaire, which contained questions about previous and current hormone use, which types of hormones were taken, treatment regimens, and duration of use. To control for confounding factors, the researchers also inquired about the women’s history of thromboembolic disorders, treatment of hypertension, heart disease, diabetes, body weight and height, smoking habits, and other factors.

Of the 2,185 women who were sent questionnaires, 1,640 responded. Of those women, 1,422 were included for analysis. Based on results of the questionnaire, the women were classified either as never-users or former users of HRT, current users of unopposed estrogen, and current users of combined estrogen and progestagen therapy.

The researchers found no significant association between HRT and the occurrence of subarachnoid hemorrhage. (Significant positive associations were found, however, for smoking and hypertension.) Neither was a significant association found between HRT and intracerebral hemmorhage or thromboembolic infarction. Former use of oral contraceptives was associated with a lower risk of thromboembolic infarction, while the presence of heart disease or Type II diabetes was associated with a higher risk.

The researchers conclude that although "substantial evidence suggests that non-artificial estrogens in physiological doses have an improving effect on factors that decrease the risk of cardiovascular disease . . . estrogen may have dual and opposite effects on the coagulation system, increasing thrombogenicity."