Dr. Charles Oberg, Chief of Pediatrics at Hennepin County Medical Center, commented in a recent editorial in Minnesota Medicine on the system fragmentation faced by high risk families. He advises undertaking a focused, interdisciplinary, and coordinated approach stating:“As a community, county, and state we should regularly collaborate to plan coordinated interventions.” (Oberg, 2000) Essential components of this coordinated approach include:

Interdisciplinary training
Interagency planning and assessment
Cultural competency and understanding
Community involvement in health care
Patient advocacy

Clearly, addressing infant mortality among the Twin Cities’ diverse communities and high-risk families requires systems that communicate well and work together to address each patient’s individual needs. Working examples of coordinated care during pregnancy and infancy follow:

The Nurse-Midwife Service at Hennepin County Medical Center
Survey results from community clinics and hospitals often cited nurse-midwives as the primary providers in the continuum of care during and after pregnancy and were interviewed about their practices for this report. The nurse-midwifery model of care incorporates all of the essential factors of primary care and case management/care coordination. Their care includes preconception counseling, care during pregnancy and childbirth, and postpartum follow-up. The model provides assessment and referrals as appropriate for the woman and her family. Such care is inclusive and integrated with the woman’s cultural, socioeconomic, and psychological factors that may influence her health status. The model ensures communication and care coordination between clinics and hospital. All pregnant women are assessed using the Minnesota Pregnancy Assessment Form (MPAF).

While in the hospital, based on needs identified during the prenatal period, families are visited by a social worker. Early Childhood Family Education and a public health nurse home visit are offered to everyone. Other possible referrals as needed include lactation consultation, medical care, and care and resources for newborns with special needs.

Appointments are made at hospital discharge for the newborn and postpartum visit. The postpartum discharge packet given to all new mothers includes information on infant symptoms requiring immediate medical attention, a number to call for advice on infant care and postpartum questions.

The nurse-midwifery model meets the challenge many practice systems are striving to achieve—an integrated continuum of care that provides for collaboration, consultation, and referral for medical and obstetrical complications as well as for psychosocial or financial needs better served by community agencies.

Prairie Regional Health Alliance: Successful Use of the MPAF
A twenty county region in southwest Minnesota received foundation funding to support the implementation of a systems approach to pregnancy and birth. This approach focuses on early initiation of prenatal care, consistent prenatal education, risk assessment and referral using the MPAF for all pregnant women, timely interventions for at risk women, effective use of community resources, and timely and effective communication among providers of prenatal care and other service providers.

This project, known as the Southwest Minnesota Integrated Prenatal Project, has required close collaboration and interdisciplinary training and communication between health care providers, hospitals, public health, health plans, and social services. Although the project was initially implemented to focus on early prenatal care and coordinated services throughout pregnancy and birth, the project’s patient-centered model, the Circle of Life, also includes family planning, preconception care, and early pregnancy recognition components. This project effectively uses the MPAF as a risk assessment, intervention, and care coordination tool for all pregnant women. With signed consent of the pregnant woman, primary care providers forward completed MPAFs to public health nurses who provide early prenatal education, offer labor/delivery education opportunities, and referral to community resources. Additional interventions are based on identified risk factors and become an individualized plan of care with the pregnant woman. The MPAF becomes a communication link among providers during pregnancy, and is also a source of population-based data for determining prevalence of risk factors, demographics, and birth outcomes that are specific to clinics and sites of delivery as well as county and regional aggregate data.

Ultimately, this systems approach to pregnancy and birth expects to demonstrate improved quality and consistency of care and improved outcomes among the annual 2000 births in the region. This project is an example of organizations coming together in a partnership to create a better perinatal system of care coordination and measures well against the Survey Framework standard of this report.

The Circle of Women
The Circle of Women is an advocacy program for high risk pregnant women in its third year in Minnesota. Programs are active at two community health centers in Minneapolis and on an Indian Reservation in northern Minnesota. The program provides ongoing case management and counseling to pregnant women for issues such as chemical dependency, domestic abuse, housing, and family planning as well as medical and perinatal issues. The advocates follow the women for three years. Many of these higher risk mothers need that long term support to begin a more self-sufficient and healthy lifestyle for themselves and their children.

The advocates have found that the system is unprepared, at best, to deal with the needs of their clients. It is extremely difficult to get housing that is safe and affordable. It is almost impossible to qualify for an effective period of chemical dependency treatment, and more impossible to have their children with them during that time.

The advocates are the central point from which the women can understand and access resources in the community when they are available, and to help challenge the system when necessary.

Without this kind of case management, the health care community cannot expect to impact the complex issues surrounding the life styles of low income high risk women. What happens to pregnant women and their newborns is much more than whether or how often they make it to the clinic or had a nurse visit. It is about making it possible for them to make health care a priority in their lives.

Turtle Women Doula Project, Ramsey County
“Doula” is a word of Greek origin referring to a woman caregiver of another woman. Currently, it describes an experienced and trained laywoman who provides continuous physical, emotional, and informational support to a mother during labor and delivery (Scott, Klaus & Klaus, 1999). Locally, the Turtle Women Doula Project of the American Indian Family Center in St. Paul serves American Indian pregnant women in Ramsey County with culturally appropriate service delivery. Working with the Community Health Nurse, the Turtle Women doulas enable pregnant women and their families to identify their strengths and to reconnect with traditional American Indian cultural practices that promote healthy pregnancy, birth, and infancy. During pregnancy, the doula translates medical advice from the clinic into clear language and teaches comfort techniques to use during labor. The doula attends the labor and delivery to support the mother and reduce her fears and stress, sometimes helping to avoid medical intervention in childbirth. The doula advocates for the mother to hospital staff helping to enhance communication and bridge cultural gaps. After birth, doulas support and educate new parents and help identify signs of postpartum blues or depression. The Turtle Women Doula Project is a community-based strategy to reduce the disparity in infant mortality experienced by American Indian families.

Washington’s First Steps Program
In August, 1989, the state of Washington implemented their First Steps program of enhanced services to Medicaid maternity patients. It includes obstetric care, public health nursing, nutrition and psychosocial counseling, childbirth education, and case management for high risk women. First Steps provides preventive health services including assessment, education, intervention, counseling, and childbirth education provided by an interdisciplinary team of public health nurses, community health workers, nutritionists, and psychosocial workers. The Washington State Department of Social and Health Services’Office of Research and Data Analysis performed a statewide evaluation of the program. It found that program implementation was correlated with decreased rates of inadequate prenatal care, decreased rates of low birth weight, and decreased rates of infant death. It also found that for every $1.00 spent on First Steps, $2.03 in future costs was avoided (Perry & Ullman, 1996).

North Carolina’s Baby Love Program
North Carolina implemented maternity care coordination, the Baby Love Program, which is aimed directly at eliminating the barriers to client use of services. All pregnant women certified for Medicaid are eligible for care coordination without need for further risk identification beyond that of low income status. Although it is a statewide program, it was implemented in stages providing an opportunity to compare the effect of the program on certain pregnancy outcome indicators with women who participated versus matched women who did not. Care coordinators provided their services full time, and placed special emphasis on nutritional, psychosocial, and resource needs. Women who did not receive these services had a low birthweight rate that was 21% higher, a very low birth weight rate that was 62% higher, and an infant mortality rate that was 23% higher. It was estimated that each dollar spent on maternity care coordination saved $2.02 in Medicaid costs for newborns up to 60 days of age (Buescher, Roth, Williams & Goforth, 1991).

Rhode Island’s RIte Care Program
When Rhode Island implemented Medicaid expansion for pregnant women and children and Medicaid managed care they determined that efforts beyond simply increasing eligibility for insurance would have to be undertaken. The five health plans collaborated to develop the RIte Care Program which implemented a number of measures to improve rates of early and adequate prenatal care. Assuring that each participant had a “medical home” was their first priority. Additional activities included: reducing barriers to enrollment, allowing patients to continue care with their current provider regardless of the provider’s plan affiliation, outreach to women of childbearing age, assuring prenatal appointments in the first trimester or by three weeks following a positive pregnancy test, assuring patient transportation and implementing one system for all five plans, and conducting a media campaign for RIte Care, not for individual health plans. Rhode Island birth certificate data confirmed that this cooperative program among plans was successful in improving adequacy of prenatal care utilization by Medicaid patients. Ongoing monitoring will continue to determine RIte Care’s effect on prenatal care and birth outcomes (Griffin, Hogan, Buescher & Leddy, 1999).

Appendix 6 References

Buescher, PA., Roth, M., Williams,D., & Goforth, C. An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina. AJPH. December, 1991. Vol. 81#12, pp. 1625-1629.

Griffin, JF., Hogan, J., Bueschner, J. & Leddy,T. The effect of a Medicaid managed care program on the adequacy of prenatal care utilization in Rhode Island. AJPH, April, 1999. Vol. 89, #4, pp. 497-501.

Oberg, C The interplay of poverty and adverse health outcomes. Minnesota Medicine, August, 2000. Vol. 83, p 20-21.

Perry,D. & Ullman, F. National Governors’ Association Report: Issue Brief: Enhanced Prenatal Care Services and Medicaid Managed Care. June, 1996.

Scott, K.D., Klaus, P. & Klaus,M. The Obstetrical and Postpartum Benefits of Continuous Support during Childbirth. Journal of Women’s Health & Gender-Based Medicine, vol 8#10, 1999, pp. 1257-1264.

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