Meetings help CMs, pregnant women bond

Incentives encourage keeping appointments

By meeting at-risk pregnant women face-to-face in their physician's office, a case manager from BlueCross BlueShield is able to successfully engage the Medicaid recipients in case management and work to meet their needs throughout the pregnancy.

"When the telephonic case managers call members, they're sometimes not open to participating in the program or think they have no need. It makes a big difference to have a person in the office who works with them face-to-face. Since we started the program in June 2012, nobody has turned us down," says Roanna Williams, RN, CCM, supervisor of case management for the Chattanooga-based health plan. BlueCross BlueShield of Tennessee covers its Medicaid members under the Volunteer State Health Plan.

The face-to-face interventions, part of the Caring Start in Your Neighborhood high-risk case management program, take place in an obstetrical practice office that treats a high volume of health plan members, many of whom are at high risk for complications of pregnancy and pre-term births.

In addition to the face-to-face program, the health plan's CaringStart program provides telephonic case management for high-risk women who see other providers during pregnancy. The health plan sends educational materials to all pregnant women.

The health plan uses its medical informatics tool to get weekly reports of women who are pregnant. The tool uses information from the state of Tennessee on newly eligible members who are pregnant, as well as claims data for prenatal vitamins, pregnancy tests, ultrasounds, or other procedures that indicate pregnancy. Referrals also come from physician offices.

The tool identifies pregnant women who have been treated for substance abuse, who had problems with a previous pregnancy, pre-term births, or other factors that indicate the women may be at risk for a preterm birth or other complications. Women who are under 17 and over 35 also are considered to be at risk.

The physician office selected for the CaringStart in Your Neighborhood program has provided office space for the health plan case manager and notifies her when at-risk members have an appointment. The case manager is in the office five days a week. A social worker shares her time between the obstetrical office and a nearby pediatric clinic. The case manager can call on behavioral health professionals as needed when members have issues such as substance abuse.

"Sometimes all three meet with the woman who has a lot of complicated needs," Williams says.

The health plan offers incentives to members in the face-to-face program. When they enroll, they receive a bag with baby supplies. They receive a gift card following every physician visit and a large gift card along with a baby bag filled with supplies when they come to their post-partum visit.

The case manager sees patients while they are waiting to see the doctor, and finds out how she can help. She educates them on healthy behaviors and what to expect during pregnancy. She does an initial assessment and reviews information from the physician office's records to find out about the home situation and the patient's social needs.

For instance, some women indicate that they are living with friends and don't have a place to live when the baby is born, or they don't have a crib or a car seat, and some don't have food in the house. Sometimes they tell the case manager about suffering domestic violence.

"It's amazing how needy this population is and how many resources they need," Williams says. The case manager is familiar with community resources that may help the member find housing assistance, help with utilities, food, and baby supplies and can call on the social worker for assistance. When the member has a lot of needs, both the social worker and the case manager help her access the assistance she requires.

Case managers in the telephonic program call the at-risk members, identify themselves as maternity nurses from the health plan, and conduct an extensive assessment to identify the women's medical issues and psychosocial needs. Based on the information they gather, they call back at least every 30 days, more often if necessary. If a woman develops gestational diabetes or hypertension, the case manager counsels her about diet, exercise, and following the medication regimen prescribed by her physician.

They follow up for 10 weeks after delivery, conduct a depression screening, discuss contraception and how to care for the baby, and reinforce the importance of a post-partum visit. They refer women with chronic illnesses to the regular case management program.

The health plan sends members a maternity tool kit with educational materials about having a healthy pregnancy, what to expect week-by-week, signs and symptoms that indicate problems, and information on the importance of regular physician visits. They reinforce the information during the phone calls.

"We try to identify pregnant women as early as possible in the pregnancy in order to have the greatest impact on the pregnancy. Our goal is to help our members have a healthy pregnancy and avoid having premature and low birth weight babies," Williams says.