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For Horizon Mercy, proper staffing is the first step toward a successful health care management program.
If you have the wrong people, it won’t work. If you don’t give them the proper resources, it won’t work," Robert Robison, MD, Horizon Mercy’s chief medical director, told those attending the Fifth Annual Congress on Managed Medicaid and Medicare.
Horizon Mercy, part of Horizon Healthcare of New Jersey Inc. in Trenton has 95 hospitals in its network that offer Get Early Maternity Services (GEMS), which ushers through 90% of Horizon Mercy’s deliveries for New Jersey Medicaid recipients.
Providing a program that works for the public is only part of the battle. GEMS also must make money.
"Our chief financial officer has to see if there is a return on investment before he will approve anything for the program," Mr. Robison said. A major step to accomplishing that: "Get clinical outcomes. Then you get the savings."
Mr. Robison said Horizon Mercy makes money by being in contact with the Medicaid recipients and their families. "We had 30,000 touches last year, that includes telephone calls and home visits." In all there are 185,000 members in Horizon Mercy’s plan.
Staying in touch with those members can be tremendously difficult. Many in the Medicaid population who need GEMS, through Horizon Mercy or another provider, become disenfranchised because they have poor access to transportation or the provider is not properly trained in cultural competencies.
"Plans must understand that different cultural groups seek pregnancy attention at different times," said Martha Fountain, who is responsible for the Utilization Management Department at Horizon Mercy. "For example, expectant Puerto Rican mothers seek treatment at a different time during the pregnancy than expectant African-American mothers."
Not getting early maternal care can end up costing the state big bucks, not to mention being bad for the health of mother and child. The cost of care from pre-term birth at 30 weeks, according to Ms. Fountain, can easily be $500,000, not including post-discharge care and long term follow-up.
One of the most important steps Horizon Mercy takes, according to Ms. Fountain, is risk stratification, dividing expectant mothers into these categories:
• High risk: A member with a past history of pre-term labor or pre-term delivery or complications with the current pregnancy.
• Moderate risk: A member with a past or current medical history that requires surveillance and appropriate interventions if and when conditions change. Members are monitored through regular telephonic outreach each trimester, which provides an opportunity for health teaching as well as early identification of changes toward high-risk status.
• Social risk: A member with psychosocial risk factors without significant medical history that could negatively impact pregnancy outcomes. Members are managed by social workers for evaluation, support, and referrals.
• Low risk: A member with no significant medical or social indicators that would put her at risk for complications of pregnancy.
Key to Horizon Mercy’s GEMS program is intense involvement by case managers to develop early positive and supportive relationships with the moms to be. Some of Horizon Mercy’s case managers call on the expectant mothers daily.
Horizon Mercy also has a gift incentive program to enhance GEMS, which includes regularly scheduled visits to participants’ obstetricians throughout their pregnancies. The office completes and signs a GEMS postcard that shows the member has completed a scheduled visit.
In addition, every trimester, the expectant mom receives a package that includes a diaper bag, baby bath towels, a bath thermometer, and educational brochures regarding a healthy pregnancy.
For the past four years, Ms. Fountain said, Horizon Mercy has operated its cellular phone loaner program. The telephones are pre-programmed to connect the program participants with Horizon Mercy in case of emergency. The phone is returned after the pregnancy.
"I haven’t come across another health plan that does this," Ms. Fountain added.