Health system focuses on at-risk pregnant women

Interventions cut length of stay, costs

A program to coordinate health care and community services for high-risk pregnant women has paid dividends for Madison, WI-based Dean Health System Inc., a multispecialty group practice with an affiliated HMO that serves about 243,000 patients in 50-plus clinics in 17 southern Wisconsin counties.

The program’s case manager works with local human services organizations to meet the medical, nutritional, financial, educational, and domestic needs of pregnant women whose socioeconomic and domestic situations reduce their chances of receiving appropriate prenatal care.

The goals of this program are to reduce the incidence of premature births, complications due to delayed prenatal care, and the use of drugs and alcohol by the patients, as well as cutting the cost of care. Since the Prenatal Care Coordination Program’s inception in 1995, the incidence of low birthweight and premature births has declined, and the gestational age for the first prenatal visit has decreased as well.

Reduced hospital charges

For example, patients who participated in the health system’s Prenatal Care Coordination Program incurred total hospital charges of $1,274 for a delivery, compared with $2,434 for women who were eligible but chose not to participate. Days in the infant intensive care unit were .35 days for program participants, compared with 1.14 days for nonparticipants. Total length of stay was 2.16 days for participants vs. 2.76 days for nonparticipants. (Instituting a successful program requires advance planning. See "Plan carefully before embarking on CM program," in this issue.)

The program started with roughly 125 patient referrals. About half were on Medicaid. Of the remaining patients, 40% were uninsured. In the third year of the program, the practice’s affiliated HMO received a contract to provide care to a Medicaid population, resulting in a dramatic increase in referrals. The program now receives about 450 referrals a year. About 40% of the patients receive "at-risk" scores during the screening process and are given the option of participating in the program.

"Members of the practice feel there is a tremendous need to increase the service to non-Medicaid-eligible patients who still present with high risk factors," says Jeanan Yasiri, administrator of service initiatives at Dean Medical Center. Physicians or other medical professionals, social workers, public health professionals, or school officials refer patients to the program.

Assessing risk

Kate Piotrzkowki, RN, the nurse case manager, meets with new referrals to ensure each patient completes the Wisconsin Pregnancy Questionnaire, a six-page risk assessment tool that covers information on education, housing status, medical history, living situation, nutritional intake, and use of tobacco, alcohol, medications, and other drugs. Questions that indicate risk are given point values, up to a maximum of 300 points. If a patient receives more than 40 points, a complete Prenatal Care Coordination care plan is developed. If women choose not to participate in the program, they are invited to call at a later date to participate, or just to ask Piotrzkowki questions.

The program has been well-received by clients, referral sources, and the rest of the community, Yasiri reports. "We are providing vulnerable patients access not just to care but in dealing with circumstances that created barriers to care," she says. (See "Communication breaks down barriers to care," in this issue.)

The program also has helped the health system collaborate with the rest of the community, promoting universal recognition of the importance of prenatal care, she adds. "We get so caught up in the day-to-day grind of dealing with different circumstances that we don’t stop to think through proactive additions in how we work that can help get people in for care," Yasiri says. Also, the program has built up Dean Health System’s reputation as a caring entity, she adds.

"As a result of their knowledge about our programs, social workers, school counselors, physicians, and other people in the community can give word-of-mouth testament to our commitment to our community," she says.