FALLING THROUGH THE CRACKS: Summary and Conclusions

For low income women in Hennepin and Ramsey Counties, eligibility for government-funded insurance often follows the diagnosis and confirmation of pregnancy. The process of applying for public program insurance, being assigned to a health plan, and procuring an appointment with a prenatal provider results in delayed care and missed opportunities for early intervention and preventive activities. This process disrupts attempts by all care providers—health plans and hospitals, community health centers, and public health nursing—to achieve the Survey Framework standard of care coordination and case management.

Health care and social service systems are fragmented by institutional, bureaucratic, and reimbursement barriers. While health plans and hospitals, community health centers, and public health nursing agencies all have admirable missions to provide quality perinatal services, this report maintains that all lack the system integration necessary to meet the multiple and complex needs of high-risk families in Hennepin and Ramsey counties. For public health nursing and community health centers, the findings suggest system capacity is also lacking due to problems with funding, reimbursement, and lagging technology. Health plan findings suggest that they have capacity issues as well, especially in terms of their focus on using telephone contact for case management rather than face-to-face comprehensive perinatal care coordination. While the telephonic case management model may serve important functions, the health plans’ description of maternity case management did not meet the Survey Framework standard defined in this report. Particularly with respect to at-risk, low-income women, this model does not appear to provide the necessary support, education, and advocacy.

Communication between health care and social service systems is poor. Poor communication among health plans, community health centers, hospitals, and public health nursing contributes to fragmented care and services. While these organizations are represented on various collaboratives addressing maternal and child health issues, the working relationships necessary to address individual client needs are lacking.

These circumstances most heavily impact populations of color, American Indians, and refugees and immigrants. These populations are over-represented in the low-income population of Hennepin and Ramsey counties and, therefore, most affected by gaps in the system. As recent demographic data have shown, these populations are growing in the urban area. If system problems are not addressed, existing racial and ethnic disparities in infant mortality and other poor birth outcomes are likely to persist and may even worsen.

Low-income women are not assured continuous health insurance throughout their childbearing years. Without continuous coverage there is no way to ensure access to primary health care, dental care, care for chronic conditions, family planning, preconception care, early pregnancy identification, and early and continuous prenatal care.

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