Health plan targets the medically underserved

Programs engage community providers, civic leaders

By collaborating with hospitals, schools, and members of the community, UPMC Health Plan is providing health care services to a population that has traditionally been underserved.

The Pittsburgh-based health plan has been awarded the Recognizing Innovation in Multicultural Health Care Award by the National Committee for Quality Assurance for providing culturally and linguistically appropriate health care services for its members in Western Pennsylvania.

The health plan provides commercial benefit plans, Medicare, and Medicaid through the Pennsylvania Medical Assistance Program.

The health plan studied the outcomes for members covered by the medical assistance program and identified areas in the community where access to medical care as well as medical care outcomes are poor compared to the commercial population.

"We concentrated on members in areas with the lowest access to health care and the lowest HEDIS scores and targeted a program to improve the delivery of health care services and subsequently the outcomes to this population," says Michael Culyba, MD, vice president of medical affairs, health disparity.

The health plan has developed three programs in the economically depressed and medically underserved areas. UPMC for You, the health plan's medical assistance program has partnered with hospitals to provide support for pregnant women and their children. Through a partnership with a community school, the health plan is ensuring that children receive preventive care, recommended vaccinations, and dental care. The third program partners with a hospital to recruit community leaders who educate residents about the health plan's disease management programs for childhood asthma and adult diabetes and cardiac disease.

The maternity program targets the Braddock area, formerly a steel workers neighborhood that is now a low income area with scarce health care services.

"Poor birth outcomes, particularly low-birth-weight infants, were significantly higher in this community than in the medical assistance population as a whole. We partnered with community hospitals and physicians in the area to improve prenatal care for women in this area," Culyba says.

Prenatal care provided

The insurer collaborated with representatives from UPMC Braddock community and McGee Women's Hospital of UPMC, physician practices that are a part of UPMC, and federally qualified health centers to improve access to prenatal care for women living in the area.

"This was accomplished by creating community awareness by engaging hospitals and practicing physicians, community agencies, and community civic leaders; by developing communication tools to inform the community of maternity programs and the value of appropriate prenatal care; and by coordinating the identification of at-risk pregnant members and referring them to appropriate clinical services, including a doula program we developed," Culyba says.

Members eligible for the program are identified primarily through an obstetrical needs assessment form that physicians are required to fill out for patients who are covered by Pennsylvania's medical assistance plans.

Women in the neighborhood are largely transient without regular access to telephone and have tremendous psycho-social needs.

"One of the issues we recognized is that telephonic disease management is not effective with this particular population. Peer-to-peer support is much more effective than someone from a corporate office calling them," Culyba says.

Working with East Liberty Family Practice, a large physician practice group, and the federally qualified health centers, UPMC Health Plan has created a doula program to provide support during pregnancy, labor and delivery, and beyond.

"Doula" is a Greek word that means a specially trained women who "mothers the mother" and assists her through pregnancy and delivery and helps her understand her role as a parent.

The health plan recruited women from the Braddock community and put them through a training and educational program that includes motivational interviewing and meets the requirements for a doula certification program.

The program provides pregnant members who chose to participate with six prenatal visits and four post-partum visits.

"When we identify a member for the program, we refer her to one of the doulas who makes personal contact and follows her through the pregnancy and delivery and helps transition her and her baby into better pediatric care," Culyba says.

The doula identifies any risks to a healthy pregnancy and points the member to services that would help. For instance, if the woman is a smoker, the doula will refer her to a smoking cessation program. If she needs transportation, housing, or food, the doula helps her access community agencies that can help with those needs.

"Our feeling is that peer-to-peer communication creates a social bond and the woman who is in need is more likely to respond," Culyba says.

The doulas communicate with UPMC's maternity program, using tools that outline their visits with the women and what headway they have made.

Magee Women's Hospital of UPMC, which performs the majority of deliveries for women in the Braddock area, allows the doulas to attend the delivery with the women and help them through the labor and delivery process.

After the baby is born, the doula makes a post-discharge follow-up visit to make sure the mother and child are doing well and that the child is getting good pediatric care.

Participants in the program have shown a significant increase in breast feeding, an increase in having a prenatal visit in the first trimester, and a decline in low-birth-weight babies.

Targeting school-age kids

In another community project, the health plan has been working for about a year with the school nurse at a community school to identify members who haven't gotten the recommended immunizations or who haven't seen a dentist. The health plan coordinates with the nurse to ensure that the children get the necessary medical care.

"UPMC Health Plan functions as a coordinating entity between the school, the child and family, and the health care practitioners," Culyba says.

If the health plan's data analysis shows that a member hasn't had a recommended immunization or isn't getting regular dental care, the health plan's care coordinator tries to get in touch with the family.

If the health plan can't contact the family and the child is a student at the school, the case manager alerts the nurse who calls the student in and talks to him or her.

"We have created a communication vehicle. If we can't contact the parent, we ask for help from the school. We know that these children have to go to school so we work with the school nurse to get in touch with the child and parent and we coordinate a visit with the primary care practitioner," he says.

The health plan has been piloting the program in one school for about a year.

The school nurse and the case manager work together to make sure the student gets the care he or she needs.

"We provide care management services for our members and work with the school nurse to improve the medical care for our members," Culyba says.

Through a partnership with UPMC Braddock, the health plan is helping people with chronic conditions who live in the Braddock community learn to manage their diseases.

With the help of the health plan, the hospital has recruited community ambassadors to educate the public about its Steps to Health program, which provides disease management for adults with diabetes and cardiac disease and children with asthma.

"We know that peer-to-peer communication is an effective way to engage members, particular those in our medical assistance programs. We want to create awareness of these disease management programs and to work with the hospital to ensure that members with these conditions are referred into our clinical program," Culyba says.

UPMC Health Plan and UPMC Braddock train the ambassadors about the health plan and hospital-based disease management programs, including how to identify people who would benefit from the program and refer them to UPMC Health Plan.

The health plan assists the hospital in developing and implementing disease management programs for people with chronic conditions who are without health insurance. The health plan has representatives on the hospital's disease management steering committee and coordinates clinical activities with the hospital to make sure that the care is consistent for all members of the community.

"The role of the hospital is changing, particularly when it is in a depressed area. Instead of just taking care of people when they're sick, the hospital's role is evolving to recognize the value of prevention and to become a leader in developing clinical programs to help prevent and manage chronic diseases," Culyba says.