AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
BELINDA ROGERS: Thank you. Good morning. I’m here today to share with, can you hear me? I’m here today to share with you an exciting, the results of an exciting program that we implemented in Oklahoma to increase access to prenatal care for pregnant women. I want to share with you the successes and challenges encountered in reaching high-risk women in Oklahoma , the project impact on increasing access to care for those women, and finally describe the role that community outreach workers played after DHS Staff reductions became a reality in Oklahoma . I’d like for you to imagine with me for just a moment. I was 19 years old, scared and angry. Not only was I five months pregnant, I was not married, deserted by the one who supposedly loved me. My parents thought it would be in my best interests to live elsewhere on my own. Alone, by myself, I gathered my belongings and bitterly moved into a shelter, my home for the next four months. Not have any sort of prenatal care and being five months pregnant, I knew that I needed care, but how and where?
In south Oklahoma City a 35 year old Hispanic pregnant woman married to a U.S. citizen has decided not to apply for Medicaid benefits to get prenatal care even though she is eligible. She believes that if she receives Medicaid her application for adjustment for permanent residency will be denied and she will be separated from her family. She has developed gestational diabetes and is in great need of financial assistance for mounting medical bills. Too many of these stories abound. Teens who are pregnant because they wanted someone to love them, women, pregnant with no health insurance who work long days. Women who saw a doctor for the first time the day their water broke because they could not afford care. These are the faces and stories of thousands of pregnant women who did not get the crucial prenatal care they needed because they could not afford it or unaware of the resources available to them or unaware of the importance of getting early care. These are merely two of the many real stories of the many real faces in Oklahoma of women without real access to prenatal care.
In looking in terms of in 2001 prior to the implementation of the Healthy Beginnings Campaign, the infant mortality rate was 17 percent higher in Oklahoma than in the U.S. We knew that over half of these deaths occurred in the neonatal period as opposed to the postnatal period. In looking at race specific data, this slide is a little hard to see, that it was highest among black infants followed by Native American whites and Hispanic. And you can see that Oklahoma in the lighter blue tended to be higher than the rates of the national average. It’s an established fact that early prenatal care is essential in a health delivery. While other states continue to improve their rates of prenatal care, one in five women in Oklahoma received inadequate care. Actually Oklahoma in 2001 ranked 43 rd worst in the nation for the number of women who sought early inadequate prenatal care. Couple this with the fact of uninsured women. Nearly one in four during 2001, women of childbearing age was uninsured in Oklahoma making Oklahoma 40 th worst in the nation for the number of women who went without a regular source of healthcare.
Yet, at this same time, Medicaid paid for nearly half, 48 percent of the births in Oklahoma . However, data revealed that in less than half of these cases did women receive the amount of adequate prenatal care. PRAMS data at this time also indicated that three out of five women delivering in 2001 were eligible for Medicaid, they lived under the federal poverty level. So it’s clear to see with these statistics that Oklahoma had a real problem, that we needed a real solution to increase the access to prenatal care. So we had an intervention. In 2001 the March of Dimes in an effort to support their national effort of increasing care, adequate care to women and children were offering MYOP Grants, which is Mission Investment Opportunity Program Grants. The Oklahoma Institute for Child Advocacy, a non-profit organization in Oklahoma City decided to apply for a MYOP Grant. It was actually awarded a Grant in 2001. So this was the March of Dimes strategy in Oklahoma to increase access to early prenatal care among low income pregnant women and to increase the knowledge base of those women about the importance of prenatal care.
The goal of the Healthy Beginnings Campaign was to improve the rates of early prenatal care in Oklahoma . It was a collaboration between the March of Dimes and the Oklahoma Institute for Child Advocacy on a three year campaign from 2002 to 2004. We were going to build upon the Covering Kids Partnership model. At that time the Institute for Child Advocacy was a Covering Kids Grantee. Covering Kids if you’re not familiar is a program, a health access initiative funded by the Robert Wood Johnson Foundation in a way to get more children enrolled into health coverage into Medicaid. At this time Oklahoma ’s Covering Kids Program had done an outstanding job of enrolling children into Medicaid. In fact, in 2000 we were recognized by the Kaiser Foundation, for leading the nation, in the number of children that we enrolled into Medicaid. So the Healthy Beginnings Campaign was designed to build upon that partnership and expand outreach.
We have three major strategies, expand outreach to pregnant women, connect these women to available health resources at the local level, and to serve as an outreach catalyst for state and community organizations. We had two main objectives in implementing the Healthy Beginnings Campaign. We were going to take the work of the DHS outreach workers to the next level. This, the DHS outreach workers were really the cornerstone of the success of the Covering Kids Project. We had DHS outreach workers in most counties, over three fourths of the counties in Oklahoma . So these DHS outreach workers were the key to success in enrolling children into Medicaid. So we were going to build upon their success and expand the outreach to pregnant women. Equip these outreach workers for knowledge at a local MCH resources, WIC, family planning, prenatal resources and also educate them on the March of Dimes educational resources.
March of Dimes offers a wonderful array of educational materials, curricula. We also are very fortunate in Oklahoma to have six March of Dimes Division Offices that we were going to connect these outreach workers to, to enhance their effort, and then conduct a statewide outreach campaign. The implementation of this project we thought would be rather seamless. Build upon the success of the DHS outreach workers, they had a strong network, it was working very well. However, that was not the case. We automatically hit an instant road block two weeks after the Institute found that they received the funding from the March of Dimes, because of massive state budget cut, the DHS outreach program was cut. We no longer had the DHS outreach workers in the counties in Oklahoma , which we were going to expand on for pregnant women. Set a huge impact on our campaign not only on the campaign but for many Oklahoma families as well. So we were left struggling, okay now what? How are going to really accomplish reaching out to pregnant women? Oh, sorry.
Okay. So we decided after much discussion with our Covering Kids Partners that we would try directly collaborating with these partners and train and provide technical assistance to their staff to do these outreach strategies for pregnant women. We started with very select pilot sites. We were going to provide intense outreach training to them, have a really a community approach. We knew that having community involvement at the local level was going to be something that was going to be key to our success, finding out what the local needs were and really accommodating those. We wanted to have very specific outreach strategies in terms of what the local community needed and be very cognizant in working at those strategies. We did provide small mini grants to these pilots to help them undertake these outreach strategies, and then of course to continue to our work as an outreach catalyst. We started with four initial pilot sites, Baby Vine, Better Babies, Cherokee Nation and Variety Health Center . These pilots were chosen on their ability on several components.
To reach high risk populations, will a patient in one of the five top highest birth rate counties in Oklahoma, and their ability to serve racially diverse populations and there willingness to work with community, the community, have their involvement and to partner with the Healthy Beginnings Campaign. Baby Vine is located in Tulsa , a county, which actually has the second highest birth rate in Oklahoma . They utilize a sophisticated information referral service. Baby Vine was established in Oklahoma and working very well for information referrals. They added an outreach component to that. They were able to provide one on one application, assistance with their clients. When they called they were, each client was screened regarding health status and if they deemed them to be eligible for Medicaid they would help them fill out an application over the phone. And then the direct referrals for pregnancy testing and prenatal care for a local clinic in Tulsa . And they were successful in helping us enroll 3,211 pregnant women into Sooner Care during the course of the three years of our campaign.
Better Babies is located in Cleveland County , which is actually the third largest high birth rate county in Oklahoma . They utilize a Promatora and for those that are not familiar with Promatora, it’s a Spanish word for a lay member of the community who is very trusted. And in addition to the Promatora, they had a bilingual outreach specialist who served as interpretation in conjunction with the Promatora. Again the key was one on one application, assistance provided by the Promatora. Better Babies is actually a provider of prenatal services, so at the time that women came in and they were able to enroll them into the Sooner Care Program, they also were a provider of prenatal services. And they successfully helped to enroll 595 pregnant women into the Sooner Care Program. Cherokee Nation, really the success for this pilot became as a result of the extensive work that the Covering Kids Partnership had established with Cherokee Nation. They had done a wonderful job of establishing trust within this Native American population in terms of Medicaid outreach. So we were able to build upon that success.
Cherokee Nation trained what they called Patient Benefit Advocates to conduct this outreach to pregnant women. These Patient Benefit Advocates provided the one-on-one application assistance and they were very creative in utilizing an incentive program. When this community looked at their rates of injuries due to lack of car seat use, they realized it was very high. So they decided to, when a woman, a pregnant woman enrolled into Sooner Care, they would give that woman a car seat, an infant car seat and it actually worked very well in this particular community and they were able to help enroll 2035 pregnant women into Sooner Care. Variety Health Center in Oklahoma City predominantly caters to Hispanic women, again the success with Covering Kids of establishing the trust within that community in terms of outreach. They utilized at Promatora again and this clinic and Promatora was very trusted in the community. They were also a provider of pregnancy testing and prenatal care.
With the community involvement, they realized that they, that this Promatora needed to be very mobile, that she could go between like Variety Health Clinic and some of there sister clinics and provide this outreach service. They actually, she actually utilized the Hispanic radio station and was very successful in talking on the radio about the importance of prenatal care and the Sooner Care Program. And Variety helped to enroll 3359 pregnant women into Sooner Care. Based on the success of our four initial pilot sites in year one, we decided to work with subsequent pilot sites in years two and three of our campaign. The WIC central office in Oklahoma County , County Health Departments in the five counties with the highest birth rates, and then the Margaret Hudson Program in Tulsa County . In the WIC central office intake workers were able to help educate women on the importance of Sooner Care. Again, one-on-one applications assistance was able to help enroll 1464 women into the program.
County Health Departments again, within the five highest birth rate counties, utilize outreach workers at those County Health Departments. They did a wonderful job of direct referrals for prenatal appointments. Some of those County Health Departments were actually providers of prenatal services and those that were actually helped to enroll the largest number of pregnant women. And overall the enrollment for County Health Departments was 2337 into the program. The Margaret Hudson Program is in Tulsa . They are really focused on reaching out to pregnant adolescents and parenting teams. We train two of their nurses to conduct outreach and enrollment activities and focus on reaching those adolescents at the time of a positive pregnancy test. And again, the one-on-one application assistance was actually key and they were also a provider of medical services for these young girls. And they actually became a pilot site in year three and did an outstanding job of enrolling 886 pregnant adolescents in just one year, the final year of our campaign.
The pilot sites shared three important components. The dedicated outreach staff, someone whose main focus was to do the outreach and enrollment. The one-on-one application assistance, I can’t stress enough was very beneficial and successful in the success of the overall program. And then again, the ability of an organization to be trusted in their community especially in the Hispanic and Native American communities we found this to be an essential key to the success. This slide shows Sooner Care enrollment over the course of the three years of the program. You can see the steady growth from year one to the final year of our program. I included this site because this is an enrollment data, monthly enrollment data by our four initial pilot sites. It’s very hard to see, but Variety Health Center , actually this graph on the far right side, shows their monthly averages actually almost doubled during the three years of the campaign.
In terms of looking at it becoming a statewide catalyst, increasing information statewide about Maternal Child Health Resources, there were several venues that we utilized, an electronic newsletter, an online resource directory, training and technical assistance and a media campaign. In terms of our newsletter we incorporated an electronic newsletter. It was sent out via email to community organizations. We did it on a quarterly basis. This system that we used actually had a built in tracking system, so we could actually track the number of folks that opened the email and even more specifically what articles within that newsletter they were clicking on so that we could keep, you know, abreast of what information these organizations were really wanting and needing. We found it to be a very cost effective means of getting Maternal Resources information to these organizations. It actually became the only statewide electronic MCH newsletter.
In terms of our online resource directory, this was something that was housed on the Oklahoma Institute for Child Advocacy’s website. And it was data specific information on Maternal Child Health Resources. You could click say for instance, on Oklahoma County and it would bring up the MCH Resources within that county. The maintenance is ongoing and was very critical to have that partnership with our, the close partnerships helping us to keep that updated on an ongoing basis. That was the key for that. And a recent edition in year three we added a second component to that. It was an oral health resource directory on county specific. Training and technical assistance, I think outside of our pilot strategies, this was the most successful strategy of the Healthy Beginnings Campaign. We were able to provide intensive training and technical assistance on an ongoing basis to community organizations, physician groups, Indian health services, organizations, state agencies and state and local MCH coalitions. In fact, this continues to be a sustaining factor component of the Healthy Beginnings Campaign.
We ended our campaign in December of this last year, but this was a very effective means of our success. The media campaign, originally we were going to conduct a statewide, very large, media campaign. The healthcare authority, which is the Medicaid managing agency in Oklahoma , was going to provide a substantial amount of in kind dollars to help conduct this media campaign. Of course, when state budget cuts hit, that was one of the first things that was cut as well. So we were scrambling, you know, as to how can we scale down this media campaign yet make it very effective. And we found that several ways were very key to that success, one of which was our corporate partnerships. We had an opportunity to partner with McDonald’s on a tray liner campaign in February of 2003. We had information on tray liners that went out to every McDonald’s restaurant statewide in Oklahoma and it contained information about the importance of early prenatal care and the Sooner Care information. It was very colorful in English on the front and then Spanish on the back.
And we found that to be a key way to disseminate information. Also we did a very small scaled down version of billboard and bus shelter advertising. We worked with a partner organization in Oklahoma County looking at some very specific zip codes of rates of inadequate prenatal care and conducted a small bus shelter and billboard campaign. Television media was a definite way that we were being, we were able to be successful. In Oklahoma County we partnered with the local Fox and WB station. They were very generous to us. They created a local PSA talking about the importance of prenatal care and the Sooner Care Program and they actually ran that pro bono for us and to date. And they started that campaign, the PSA, in the latter half of the second year and then into the third year and they helped to provide actually over $100,000 worth of free advertising for us. So that was a very key partnership that we established. In terms of media success especially in the Hispanic community, within the
Hispanic population, those newspapers, we ran articles on the importance of early care and the Healthy Beginnings Campaign and how to express the information about the Variety Health Clinic that pregnant women could go there for services. Campaign results. Over 13,000 people were trained on Sooner Care Outreach and Enrollment Activities. Technical assistance on an ongoing basis provided to over 300 organizations during the three years of the campaign. And the most success, the enrollment of nearly 15,000 pregnant women into Sooner Care, over the course of the three years of our project. In terms take home messages or lessons learned, removing financial barriers through prenatal care and Lynsey touched on this is key. We found that many women in Oklahoma were unaware of the Sooner Care Program, were unaware that they would qualify for the program. So removing those financial barriers and allowing women to seek care was key. Also involving the community in planning and the implementation was key.
It’s at the core of the local community needs and really figuring out what is in the community, what they need, and how to really establish and meet those needs. Reducing system barriers by strong referral links for care. We found that the clinics that provided prenatal care or pregnancy testing were the most successful. Having that very strong link that once you helped a woman enroll into the Sooner Care Program, having that strong link to hook them up with a prenatal appointment was key. And then finally marketing services through media, education, and web based needs. We found much to our surprise that web based, getting the information out through the Internet, even for clients and community organizations was very successful for us. Other key outcomes, in looking at system changes at the policy level, maintaining eligibility for pregnant women I think is key. There were threats every year of the three years of our campaign of cuts to the eligibility level for pregnant women.
Our partner organizations and the staff at the Healthy Beginnings Campaign were strong advocates in Oklahoma and we were very lucky to have maintained eligibility in Oklahoma . Were very glad that Oklahoma has done so. In terms of looking at forward prenatal care for undocumented Hispanic women, dialog has started in Oklahoma , that’s something that is a work in progress. Right now Medicaid pays for the delivery but not the prenatal care undocumented women and it’s something that we hope to achieve in Oklahoma . I put this slide in. It’s a quote from Margaret Mead because I think it really gets to the heart of the Healthy Beginnings Success. We had many challenges going into the program but without the dedication of the staff and our partner organizations and the collaboration and their dedication was really the key to our success. It says never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it is the only thing that ever has. Thank you.