Plan offers 3 steps to healthy pregnancy

Program provides CM for at-risk members

Passport Health Plan's Mommy Steps program helps at-risk pregnant Medicaid recipients get the care and psychosocial help they need to overcome the obstacles to a healthy pregnancy.

The Louisville, KY health plan's performance consistently exceeds the state of Kentucky's goals for managing the care of at-risk pregnant women.

"The Medicaid population faces a lot of challenges in receiving timely prenatal care and keeping appointments. We want to identify pregnant women as early as possible and ensure that they have regular visits with an obstetrician or a family practitioner who does obstetrics," says Sherry Rumbaugh, RN, BSN, director of care coordination and quality.

The Mommy Steps Program focuses on three steps to a healthy pregnancy: regular doctor visits, healthy eating, and making good choices.

The health plan provided initial funding through a grant and has partnered with the University of Louisville Hospital's Center for Women and Infants to promote its Kangaroo Care initiative, a program to increase breastfeeding among women on Medicaid. The Kangaroo Care program has received Outcomes Improvements grants from Passport to share the program with other hospitals in Kentucky. Today, 92% of birthing hospitals in Kentucky use the Kangaroo Care method, according to Denise Barbier, OTR/L, MOT, CLC, director of the program.

Kangaroo Care calls for skin-to-skin contact between the mother and infant in the delivery room to encourage the baby to breastfeed and bond with the mother. (For more information on Kangaroo Care, visit www.kangaroomothercare.com.)

To zero-in on at-risk members, the health plan analyzed adverse pregnancy outcomes for one year to determine what could have caused premature birth, low birth weight, or very low birth weight. "We had always stratified members into low-risk and high-risk categories but we decided to take a closer look. We examined information in the claims system and our obstetrical database and revised our list of high-risk conditions," Rumbaugh says.

Conditions that stratify women into the high-risk category include preterm labor or delivery with any pregnancy, premature rupture of membranes with any pregnancy, an incompetent cervix in any pregnancy, multi-fetal pregnancy with current pregnancy, pregnancy-induced hypertension with any pregnancy, chronic hypertension with any pregnancy, substance abuse with current pregnancy, and teenage pregnancy.

Beginning in 2012, the health plan asks providers to fax the American College of Obstetrics and Gynecology standard form for obstetrical care or a similar form to the health plan after the initial obstetrical visit. "This form gives us patient history and current risk factors and enables us to get a good idea of the patient's condition," she says.

The health plan sends low-risk members a welcome letter asking them to call to update their information along with a Mommy Steps book, written by health plan staff, that educates them on what to expect during pregnancy and postpartum and during the baby's first few months.

The health plan's case management technicians call low-risk members between 22 and 24 weeks to educate them on signs that indicate when they should call their doctor. "Back pressure, bleeding, and leaky amniotic fluid are all warning signs that members may not recognize until it's too late and they're in labor," she says.

The case management technicians are not licensed clinicians but they have been trained to educate the members. If the member is having problems, the call is transferred to a nurse.

The technicians call the low-risk members again two weeks after the baby is born to screen for postpartum depression and remind the member to enroll the baby in the health plan. They call four weeks after delivery to make sure the member has a follow-up appointment and find out if she needs help with transportation.

High-risk members receive interventions from the case management technicians as well as calls from nurse care coordinators with experience in obstetrics and/or postpartum care. Early in the pregnancy, the care coordinators contact the women at one-month intervals, or more often if needed, and increase the frequency as the pregnancy progresses. They follow them for eight weeks after delivery.

If women have complex conditions or don't understand their instructions or their medication regimen, the care coordinator may accompany them to their doctor visit and assist the provider in helping the member understand.

The case managers work to build trust with the members, and most eventually participate in the program. "They see that we can help them with resources like cribs and housing assistance and that makes us non-threatening," says Julie Wildt, RN, BSN, CCM, manager of care coordination.

All of the case managers throughout Passport keep binders of community resources and share the information with each other.

"Regardless of the program they're in, our care coordinators all run into the same barriers, and they're great about sharing resources," Wildt says.

"Women on Medicaid are struggling to keep a roof over their heads, to be safe, to have food to eat every day, and resources to get to the grocery store, the drug store, and the doctor's office. With all of these challenges, it's hard for them to focus on their pregnancy," Rumbaugh says.

Passport Health tailors its prenatal programs to meet the needs of the Louisville area's growing immigrant population. Because there's a large Hispanic population in the area, the health plan has translated its educational materials into Spanish and employs a Spanish-speaking case management technician.

When the Louisville area had a huge influx of pregnant Somali women, the health plan rewrote its "Mommy and Me" book in the Somali-Bantu language and held weekly meetings for the Somali women at a community organization to educate them on the American healthcare system and answer questions. One of the nurse care coordinators attended the meeting and was assisted by a translator.

"It's hard to be in a country when nobody speaks your language and you're pregnant. We learned a lot about the Somali culture and all of the women delivered with no major complications," Rumbaugh says.

To address the challenges facing families with premature infants, the health plan has embedded two nurses with neonatal intensive care unit (NICU) experience in the NICU of a local hospital to educate mothers on caring for the tiny infants. The nurses perform both utilization management and case management, Rumbaugh says. "They are in the hospital, monitoring the baby's progress every day, reviewing the records, and working with the family as they progress toward discharge," she says. The nurses make sure the families have everything they need for a safe discharge, including a place to live, supplies such as a crib, and durable medical equipment they will need to monitor and care for the baby at home. They follow the women and babies after discharge and make sure they get to their appointments and learn to navigate the healthcare system.

"It's not unusual for a premature baby to go home with four or more appointments with providers. It's a challenge for any family, but it's overwhelming to women who already have so many social issues," she says.