AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
JUDITH CASH: In the true spirit of this collaborative project Nancy and I are going to sort of tag team this presentation and hope that you don’t feel like there’s a tennis match going back and forth between the two of us. You might just stick those, right there. We’re going to talk with you about a unique partnership in Virginia between a managed care organization and a statewide community based network of partnerships. We’re going to introduce each of the organizations that participate in this collaboration and just tell you briefly about those organizations, give you a little bit of the background and history and the rationale of this project, how we came up with the idea and why we thought it would work. Then we’re going to talk with you about the program model itself and some of the unique features of the model. We will share some evaluation data with you and interestingly enough, doctors Collins and Lou this morning I think really set us all up well for this presentation as they discussed clearly some of the limitations that we all work with in trying to make a change in prenatal health and birth outcomes and some or our evaluation data will in fact reflect some of those challenges, and finally as a result of that, share some lessons that we’ve learned along the way. Go ahead.
NANCY JALLO: I’m Nancy and I am the OB program coordinator for Centura Optima Health. And Centura is actually integrated health care delivery system and optima health is the health plan division of Centura Health Care. It’s the second largest commercial and largest Medicaid managed care provider in Virginia . And last year we had approximately 7,000 births and two thirds of those were the Medicaid managed care population. And currently we’ve got a program, an OB program called Partners in Pregnancy, which is what I coordinate. And it’s a telephonic case management program that is really based on Center for Healthcare Strategy, (inaudible) typology of identification, stratification, outreach in intervention and evaluation, which we’ll certainly talk more about.
JUDITH CASH: Whenever I talk with friends and colleagues from other parts of the country, I always have to start by saying CHIP of Virginia is not that SCHIP. We are not the State Child Health Insurance Program. In Virginia that is known as FAMIS, Family Access to Medical Insurance Security. CHIP of Virginia actually preceded Congress’s passage of S Chip legislation and so we often have the confusion with the name. We work very closely with the State Child Health Insurance Program but we are in fact a state wide network of local, public, private partnerships that employ teams of nurses and community outreach workers who work with families, low income families around the health of their children. We have typically targeted low-income families with children from birth through age six with the focus being on improving their child health outcomes by improving access to care. We are located in 30 communities around Virginia and from a government structure have a wide range of government’s relationships.
Some of our projects are located within the local Public Health System. Some of them are partner agencies with Community Health Centers or Community Action Agencies, and some of them are themselves private, non-profit organizations. But they all deliver this model of services based on a set of quality standards developed by the state network, which is based on the belief that home-based services for young children and their families is the way to really make a significant impact in their lives. As I said, our target has typically been children from birth through age six and with this project we became more and more involved with women at earlier stages of their pregnancy, recognizing that the earlier we get started, the better.
NANCY JALLO: Why we thought this would work? We actually had multiple reasons why we thought this would work. Probably first and foremost is our incredible forward thinking leadership team. Our Medical Director Dr. Dave Lavin and Karen Brayard, Director of Disease Management of which OB falls under, believe it or not, really new from the inception of the program for partners in pregnancy that we needed this piece. Being telephonic case management, we think we can really make a tremendous impact, but we still needed that high touch piece of it. And almost from day one, we knew that we wanted to do this. So we thought that was critical to the success of the collaboration. I think the second reason why we thought this would work is actually the program with Partners in Pregnancy and the collaboration is very much based on the framework that Dr. Collins and Liu talked about this morning, much about stress management, early identification and treatment of infection, and those were sort of our key messages, if you will, for all of us, going out and touching the moms.
The other reason we thought it would work is that we looked at historical data to try to figure out where are the areas that need this tremendous resource, the best if you will, that needs it the most. And so we looked at some geographic data, we looked at some other outcome data and we chose the sites basically based on that of course as well as the sites that CHIP served, so we thought that was a great way to identify potential areas. The fourth reason we thought it would work is we actually got a March of Dimes Grant to do the training. So we had all the sites come together. We did some joint training several times for consistency to kind of iron out the process issues and that actually again was very, very helpful. And then I think the other really reason why we thought this would work, is because of the track record of CHIP, knowing that they can provide flexible, individual family care and modify their needs based on what the families need.
So what’s the program aim? You know, there’s a lot of discussion as far as what should we be looking at? And actually we ended up, to look at, to reduce the number of days and dollars spent in the newborn intensive care unit, or the NICU, by infants born to these higher risk moms. And we really thought the goal of our program is pregnancy prolongation. If we can just keep them in the uterus a little bit longer maybe they can get a little bit bigger and that we thought probably NICU days and dollars might be a pretty good proxy for that. So that’s why we decided on that. We still look at pre term birth and low birth weight data, that’s our ultimate goal but initially this is the first indicator that we’re looking at.
JUDITH CASH: Talk a little bit about the program model and as you’ll see in a few minutes when we look at some of the profiles of some of the women that we’re serving, this is clearly a very high-risk population and we will look at some of those risk factors. The model is designed to provide home-based services. We see home visiting as a strategy through which we deliver the services and they’re delivered by teams of registered nurses and community outreach workers. And the team approach has been critical to the success of this model over the years. We recognize that the registered nurses clearly have a great deal to bring to the relationship as do the community outreach workers who most often come from the community that they serve. So they’ve been, they’ve walked in the moccasins, they know the informal as well as the formal resources within a local community and really are able to help women to make those connections that they have made themselves often times.
The case management efforts focus on both prenatal health and reduction of high-risk behaviors. And when we talk about prenatal health, we really think of that in a broad and global way. It’s again, as we heard this morning, I believe Dr. Liu mentioned at some point recognizing all of the factors that many of these women have to deal with in terms of lack of housing, and substance abuse, and family violence, all of those things are part of what we see as factors affecting prenatal health. So we’re not just looking at are we getting to prenatal appointments and are we gaining weight and are we monitoring diabetes for example, but we’re really looking at all of those factors that clearly will have an impact on the pregnancy and ultimately on the birth outcomes. And finally we knew that we had to really track a wide range, a wide-ranging set of data including both process and outcomes. So we’re looking of course, at attendance of prenatal appointments. Are we helping women to really maintain that good quality prenatal care, looking at stress reduction and the use of stress management techniques? Again doctors Collins and Liu talked this morning about the impact of stress on the developing baby and we certainly know from our history and our experience, that this is significant, so we look at how can we help moms to identify their stress level and then to identify mechanisms that will help them to manage that stress. Cessation of alcohol and other drug use, cessation of reduction of smoking, and certainly as Nancy mentioned, ultimately we’re looking for good birth outcomes and reduction of NICU days and dollars.
NANCY JALLO: I think the unique program features and part of this was just from the look reviews, some of it was just over on clinical observations, that we really do stick to the guideline of referring 22, 24 weeks, rarely do we go past 26 weeks of pregnancy and that’s basically just because we know the longer they’re in a program the greater the potential for impact. So we made that philosophical cut. It seems to be supported in the literature and so we do use that pretty strictly as far as the cut, 22, 24 weeks. Prenatal risk assessment like Judith talked about, we actually collaborated and developed a form, looking at all these components. Every time the moms are encountered either with a home visit or even a telephonic intervention, we do an on going risk assessment, the same kinds of things, you know.
What are your stress levels? What are you using for stress reduction? Environment, social conditions, just everything that we can think of, and again, encompassing the medical, which is a piece, but also knowing that the psychosocial and the environmental factors are huge and that’s really what we count on our eyes and ears being the CHIP workers in the home to help us evaluate. Same thing with home visits, we know the intensity of service is a key factor in positive outcomes. And so between the two agencies we kind of came up with at least every three weeks and many times those moms are seen more often than every three. And then regular contact between the field base staff, of course, which are Judith’s folks, and the outreach workers and then the health plan case managers. So once a month, all the sites, and there’s six sites. Independently we have telephone case conferences and we talk about each of the moms. What do they do when? What can we do to help them? What are some brain storming opportunities and how they come in? And it’s been a tremendous, I think, value in the program is our constant staying in touch between the two agencies.
JUDITH CASH: So what happens basically? The health plan identifies women within the health plan who they think are high-risk. And they refer those women then to the local CHIP projects. This is the profile of some of those, of the women that they refer to us. Clearly they’re a young group. We know, of course, that maternal age is a risk factor for a poor birth outcome and clearly the average age is 22 years, almost half of them are teenagers. Overwhelming majority are African American. Thirty-five percent of them have a chronic medical condition. So hyper tension, asthma, diabetes, that includes diagnosed mental illness but we also know there are many, many women who have undiagnosed mental illness. We have many, many women who are dealing with undiagnosed depression and those aren’t even included in that 35 percent. Twenty-four percent of them have had a previous preterm delivery, so we know again that’s a risk factor as well as those who have had a previous low term, low birth weight baby. And you know, you think about it, the average age is 22 years and they already have two children.
So we’re talking about women who are dealing with multiple stressors, multiple risk factors, fewer of them are married. Again this morning we heard about the impact of the male involvement and clearly most of the women that we see not only don’t have a partner to whom they are married, but for many of them the male partner is not at all involved. We do a number of point in time surveys with our population and at any given point in time, as many as 50 to 75 percent of the male partners, fathers of the infants that we are working with are incarcerated. So clearly, it’s a high population of women who don’t have male partner support. And finally, only about a third of them have completed high school or a GED. Some of the other self sufficiency and family security factors that our families are dealing with, 27 percent of them have moved two or more times in the last year. Many of them needed transportation but couldn’t get it.
The previous speaker talked about the problems with access of care in the rural areas. In deed, most of the sites that this project works with, CHIP has sites all over Virginia and very rural as well as urban areas. But most of the projects are engaged in, in this particular partnership are in fact in our urban areas and yet access to transportation is still a problem for many of them. And we certainly have problems with food insecurity even though many of these folks are eligible for and some of them receive food stamps, there still is a problem with food security and many of them report that they needed food in the last year but were unable to afford it.
NANCY JALLO: So hopefully we’ve sort of set the stage. We’ve got a high-risk group that are, the highest of need for the services. They’re being stratified over to CHIP and they’ve got interventions going on, pretty intensive interventions. So when we look at outcome data and remember we were looking at NICU days and dollars as just one proxy measure if you will for health. When you look at this, we said 15.2 percent of infants in the intervention group were admitted to the NICU compared to 12 percent of the control group. And the one thing that we have found with every other project, I’m sure everybody has been involved in, it really depends on your data and what you can compare to. The control group in this group is everyone who delivered with the health plan, be it commercial, be it family care, which is the Medicaid, be it regardless of ethnicity or race. We can’t actually right now separate out those of control for that. We’re looking at streamlining it and changing our database a little bit.
So that’s who we’re comparing them to, is to everybody else who delivers. So they were up. Is that to be expected? We don’t know, I mean, again, there’s really no baseline for as far as what we’re shooting for. We would like for everyone to have equal outcomes. That is our ultimate goal. The NICU admissions for intervention group, it was, they did cost more, $3000 more. Same thing, we don’t have baseline data from before the group so we’re not really sure that still may be a tremendous savings. It may not. And then infants admitted to the NICU from intervention group had a length of stay of 1.06 days longer. Believe it or not, everyone is still very, very optimistic about the program, recognizing that it’s a small number, it was about 100, less than 150 moms included in the intervention group in a very large control group.
JUDITH CASH: Other thing of course, we’re looking at are the birth outcomes. What kind of difference might we be making in terms of preterm delivery and low birth weight? And again, when we first look at these numbers, we think, we’ve got a long way to go. Clearly in Virginia , we’re looking at about one in nine, one in eight babies being born at low birth weight. These numbers aren’t so good. But again, we look at the population that we’re working with. This is a very high-risk population of whom all of them clearly are at risk for preterm delivery or a low birthrate baby. So if we look at it that way and think okay, given that all of them are at high risk for a poor birth outcome, the fact that 25 percent of them delivered preterm and 22 percent delivered a baby at low birth weight, unfortunately, we continue to look both in the literature and around the country in terms of other practices for good comparison data and it continues to be difficult to find when you’re looking at a very targeted, very high-risk population. And we continue to look for that and to look to bring these numbers down.
So we still recognize that in terms of our evaluation, we have a long way to go.
NANCY JALLO: But we like our process measures. We think those actually look very, very encouraging for all of us and 81 percent reported using stress management techniques and I think this is incredible given the life history of these moms and that, you know, a lot of them are just trying to figure out how they are going to eat their next meal. So for 81 to say that they’re using some kind of stress management we thought was really, really, again, optimistic. Twenty-seven reported decreasing of stopping smoking during pregnancy. That was optimistic. That’s another area that we really want to put a lot of emphasis this year is smoking. And then there was an increase in attendance at scheduled prenatal appointments, and believe it or not, that was actually when you looked at the control group of all that, other group I was talking about, this intervention group actually had an increase in attendance and we thought that was promising. Because again, remember one of our aims was to look at things like early recognition and signs and symptoms of infection. So if they’re going to their prenatal and scheduled visits, hopefully that’s an opportunity for that to occur.
JUDITH CASH: So what have we learned? Much like you all probably have learned in this field and continue to learn every day, it’s hard work and there are a lot of factors that contribute to whether or not interventions are successful. And in fact, as I’m sure most of you know, one of the things that we continue to learn is that for many of these very high risk women, the greatest risk factors, really are not as related to the medical risks of pregnancy as they are to some of the psychosocial issues, the substance abuse, the family violence, the mental illness, the insecure housing, all of these factors play a significant role in women’s ability to maintain pregnancy to term and deliver healthy babies. We know this is a difficult population to engage and retain. One of the things that we are really focusing a great deal of our efforts on are retaining women in the project, helping them to stay engaged. Our outreach workers work very hard and are very creative in finding women who are difficult to find and helping them to gain access to services and to stay engaged in the project.
Certainly, you know, we often times hear about programs and projects in which, participants are non compliant. And we believe very strongly that participants are non compliant because we’re not meeting their needs. And that’s really our problem not their problem. And so we work very hard to identify the best ways that we can meet the needs of the women that are engaged in the project and continue to meet those needs based on the way they define them. As I said, we recognize that there’s a lot of need for creative outreach. Often times these women are engaged in multiple systems and helping to access those multiple systems and knowing where they are is critical. Frequent contact, as Nancy mentioned, we’ve determined a minimum interaction or every three weeks but for many of them it’s much more frequently than that because the frequent contact is so critical.
Many of these women are in crisis a lot. And so we help them to manage those, crisis and prevent future ones. And incentives, you know, whether it’s bringing water bottles or written materials or diaper bags or whatever it happens to be, clearly the hook often is one that’s helpful to get them engaged. And once we’ve gotten them engaged, often times that’s all it takes. But there is a need often to have some incentives that will keep things interesting. And the other thing that we’ve seen too is that, often while we do see more preterm deliveries that we’d like to, oftentimes those babies are still healthier. So we’ve got, you know, healthy 36 weekers who really don’t spend very much time if any in the NICU and that’s one of the things, that as Nancy said, if we can keep them in as long as possible, prolong the pregnancy as long as possible, that’s really our goal.
NANCY JALLO: And I think we would all agree that at least Judith and I and our management as well, that a collaboration between a managed care and a home visitation like CHIP is a wonderful opportunity and we will plan to continue it.
JUDITH CASH: Thank you. Our contact information is in the packet of handouts and I think we’ll take questions at the end? Okay.