The secrets to serving Medicaid moms

The keys are constant support and hands-on care

Maternal and newborn expenses account for 25% to 40% of payers’ total health expenses, making perinatal outcomes of vital interest to payers and providers. For managed Medicaid plans, the cost runs even higher unless, of course, case management programs step in to identify and support women at risk for preterm delivery.

Two programs in different regions of the country are successfully reducing the incidence of preterm birth and low birthweight babies using two very different approaches. Health Management Corporation (HMC), a disease management company in Richmond, VA, uses a medical model perinatal program staffed by perinatal nurses. The program saved $300,000 in a 12-month period for 359 women in one of its managed Medicaid plans. Chicago Health Connections trains community leaders with little formal education to support and educate low-income, pregnant teens with similarly satisfying results.

As different as these two programs are, they both begin by using a variety of methods to recruit a sometimes difficult-to-reach population into their perinatal programs.

"We catch women during enrollment interviews, through claims, or precertification, but sometimes it takes a visit from an outreach worker to actually get the pregnant woman enrolled in the [Baby Benefits Maternity Management] program," says Robin F. Faust, director of program and market development for HMC. "For commercial populations, you can get the referral from the obstetrician’s office, mail a questionnaire, and it comes back filled in. With this population, that doesn’t work."

"You are serving a population that has not received this type of service in the past," says Rachel Abramson, RN, MS, IBCLC, executive director of the Chicago Health Connection. "Most of the teens we serve are part of a program called ‘Parent too Soon.’ We find it helps if we are introduced to the teen through their ‘Parent too Soon’ home visitor," she says.

Registration aside, the two programs take different approaches to perinatal education and support services. (See diagram, inserted in this issue, for the HMC program model.) The HMC program’s medical model uses perinatal nurses with a minimum of five years of training. The Chicago Health Connections program uses onclinical community members the agency trains itself.

HMC conducts a perinatal risk assessment of enrolled women by telephone or in the home. "I think that sometimes the phone works best for this population. The women seem more comfortable," says Faust. "Many of these women have no running water or indoor bathrooms in their homes. They are less likely to feel that the nurse is judging them if the nurse can’t see their environment."

Women are classified as low or high risk for preterm delivery based on a perinatal risk assessment. "The assessment is done in a conversational way. Sometimes the women don’t even realize they are being assessed. We probe gently and use any opening to do some teaching. We want the assessment to be user-friendly. It’s more like a teaching guide than an assessment," says Faust.

Low-risk women receive a package of educational materials and access to a 24-hour toll-free number staffed by nurses. Women are reassessed at 26 to 28 weeks to make sure there is no change in their risk status.

High-risk women are assigned a personal nurse to work with them throughout their pregnancies. The nurse calls them on a regular basis. "Nurses help arrange transportation to doctor’s visits, monitor compliance with doctor’s orders, make sure they keep appointments, and arrange a wide range of supplementary services, as needed," says Faust. "The nurse plays social worker, health educator, counselor."

HMC decreased the incidence of preterm and low birthweight babies with its medical model. It also found that women who received home health visits had better birth outcomes than women who did not. (See bar graph, above.)

That’s just what Chicago Health Connections believes makes the difference for its clients, as well. "We use a high-touch, low-tech approach," Abramson says. "These women’s lives are constantly complicated, and many have little or no support system. We deal constantly with the stressors these girls live with."

Chicago Health Connections received four years of funding from the Robert Wood Johnson Foundation in Princeton, NJ, to train community women as doulas (paraprofessionals who provide perinatal support) for teens on Medicaid. "The strength of the program is that it is relationship-based. These girls are more willing to ask for help from someone they trust and can identify with," Abramson says.

Chicago Health Connections partnered with three area agencies to staff the doula program. "Each agency serves a different section of the city," she says. "Each group selected women in their own neighborhood to receive doula training."

Agencies chose women who were natural leaders in their communities, not necessarily those who had achieved a particular education status. Doulas received three months of training totalling 60 to 70 hours of classroom time and observed at least three births. "Doulas also had to have extensive community-based clinical observations in medical clinics or post-partum units," Abramson says.

The doula training was based on training provided by the Doulas of North America (DONA), a certifying agency in Seattle. "However, DONA assumes a high literacy level and the ability to read and digest a great deal of clinical information. We had to adapt the training program to a community level without high education and literacy. We used an approach that looks at the learning situation as a dialogue between the community participant and the trained facilitator."

Doula training covered:

• pregnancy, labor, and delivery;

• providing counseling and support;

• dealing with common issues, such as domestic violence;

• connecting teens with other services.

Doulas are introduced to the teens during their pregnancies by a home visitor from the "Parent too Soon" program. "The doula takes on the role of facilitating prenatal education and helping the teen develop a birth plan which includes how the teen and her doula will get to the hospital. Doulas continue to support the girls for six weeks after delivery with lactation counseling, baby care, and perinatal care," Abramson says.

"Doulas visit these girls as often as weekly throughout their pregnancy. Many of these girls have no support at all. They used to end up delivering alone at the hospital. Now, their doula comes with them and supports them throughout their labor," she says.

Chicago Health Connections has gone into area hospitals to explain the program to physicians and nurses. The agency has been so successful that hospitals now call them for support. "We had one hospital call us and say they had a client due to deliver tomorrow who really needed someone. They asked us if there was a doula we could send. When doulas show up at the hospital with teens, they are welcomed. They really make a difference," says Abramson.

Her organization makes it very clear that the doula role is not a clinical one. "These women aren’t nurses. They’re not childbirth educators. They‘re to support the mother and communicate to her information she needs to know. We give doulas specific guidelines for when they need to call for professional help or refer the girl to a professional," she stresses.

"We feel strongly that the women in the community are the best qualified to deliver this support. Some of our intent is community development. As professionals, we go in and make clients healthy and leave. By developing leadership within communities, the support continues on an ongoing basis," Abramson says.

Whether the support comes over the telephone from a qualified nurse or face-to-face from a doula, the secrets to better birth outcomes for Medicaid populations are support and education, say Faust and Abramson.

"You have to be creative as you reach out to this population. You have to maintain a caring attitude and respect. There are cases when only face-to-face intervention will do. But these programs can successfully extend the physician’s care into the home environment with additional education and support that the physician’s offices just can’t offer," Faust says. "The perinatal program has also helped managed Medicaid plans increase their member retention."

[Editor’s note: For more information on Doulas of North America, contact: DONA, 1100 23rd Ave. E, Seattle, WA 98112. Telephone: (206) 324-5440. For more information about Health Management Corporation, contact: HMC, P.O. Box 26106, Richmond, VA 23260. Telephone: (804) 289-5020.]