Standard clinical forms: The pitfalls and benefits
Standard clinical forms: The pitfalls and benefits
One of the key components to the success of a collaborative approach to better care for Philadelphia’s high-risk Medicaid recipients is the universal prenatal encounter form (UPEF). As you might imagine, designing the form was a mammoth goal, especially when four competing HMOs were the principle players. However, the initiative, Healthier Babies Inc., pulled it off.
Project champion Richard Baron, MD, FACP, explains how the collaborative works. He is chief executive officer and president of Health Partners, the only nonprofit HMO member of the coalition. (To learn more about the coalition-building venture and emerging findings from the Healthier Babies’ database, see this month’s cover story.)
Baron and his colleagues approached the daunting task of designing a common prenatal encounter form with a few preconceptions. Some proved useful, while others did not:
• Collect social risk factors data. The presence of behaviors such as alcohol or tobacco use automatically triggers supplemental interventions.
• Limit the form to one page — a "big mistake!" To cover intake data as well as follow-up and postpartum visits, UPEF Version 1 came off the press on legal-size sheets. "The doctors hated it because it didn’t fit into their files and was hard to photocopy," Baron says. They immediately scrapped it for Version 2, comprised of separate, letter-size intake and follow-up forms. Providers prefer it overwhelmingly to one odd-size piece. Still, he notes, "we left out things we wish we had captured, such as flu immunization, which is now required by Medicaid."
• Integrate the new form into the existing office practice. Providers have few objections to the UPEF. It’s a clinically useful tool. And, it relieves some of their administrative irritations, provides continuity for patients who switch plans, and fits neatly into their file folders, cabinets, and copy machines.
Early practice changes and policy insights
The rapid information feedback from the UPEFs has expedited medical and lifestyle interventions:
• HMO staff send the names of women with HIV to the pharmacy to confirm that they have current AZT (zidovudine) prescriptions and that the prescriptions are filled on a timely basis. Staff ask the provider to follow up on any questions about adherence to medication regimens.
• The names of high-risk pregnant women are sent to a community project that provides one-way cell phones and transportation enabling homeless or low-income women to stay in touch with their providers.
Even one encounter with a participating HMO automatically connects a pregnant woman to supplemental services if she reports any risk factors, such as domestic abuse, substance use, or homelessness.
However, Healthier Babies cannot reach the 30% of Medicaid-insured women who never seek prenatal services, explains Deneen Vojta, MD, senior vice president for medical affairs and chief medical officer for Health Partners. "They are the extremely high-risk population," she says. To address that gap, the Pennsylvania Medicaid office is working to simplify the HMO enrollment process.
Emerging statistics from the Healthier Babies database promise exciting possibilities to providers and Medicaid policy-makers. Already they’ve corrected one misconception about the service-seeking behaviors of this population.
Administrators used to read low postpartum follow-up rates as failure to obtain care after delivery. But the data reveal that most women elect to visit a family planning clinic instead of an obstetrician. Based on the finding, Medicaid policy-makers could reorganize the maternity care payment system, Vojta explains. One possibility would be to parse out prenatal and postpartum fees to obstetricians and family planning clinics instead of paying global maternity care fees to obstetricians.
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