FALLING THROUGH THE CRACKS: Theory and Survey Framework

After reviewing the literature on perinatal case management and care coordination, two documents were selected to provide a framework for the study. The first, Public Health Interventions: Examples From Public Health Nursing (Keller, Strohschein, Lia-Hoagberg, & Schaffer, 1998) describes a model of case management and care coordination interventions suitable for use with this project. Several expert public health panels conducted a literature review and developed a set of “best practices”supporting each type of intervention specified in the model. Further, funding provided by the Centers for Disease Control and Prevention (CDC) enabled nationwide presentations of the model through interactive satellite broadcasts.

The theory underlying this model combines the concept of “the community as client” with a traditional epidemiological approach, which draws inferences about the etiology of illness from population-based data. Keller and colleagues also modified the standard classification scheme constructed by previous authors. Earlier writers used only two categories to classify public health interventions: (1) individual-focused and (2) community-focused interventions. The Keller group added a third focus—a systems-level category—creating a more complex classification structure with greater depth. Furthermore, the addition of a systems level reflects more accurately the nature of current public health practice.

In addition, an earlier document—Coordinating Prenatal Care, prepared by the National Governor’s Association (Hill & Breyel, 1989)—was used by the Perinatal Survey Team to narrow the Keller et al. model from its original application (i.e., the entire field of public health) to a specific focus on perinatal practice. These two documents provided definitions and a framework against which the survey team measured the performance of the local perinatal care coordination system.

Definition of Perinatal Case Management/Care Coordination

Perinatal case management and care coordination are terms used interchangeably and simultaneously to describe a role, a process, and a service within a system of care. It is a client-centered, goal-oriented process for:

(1) assessing the needs of a pregnant woman and her family for particular health and social services such as mental health, chemical dependency treatment, housing, and other advocacy;
(2) assisting women in obtaining those services; and
(3) coordinating those services to avoid gaps and duplication. It is an ongoing activity that continues until established goals are met.

As a role, case management/care coordination (CM/CC) provides a client with a practitioner who actively coordinates her care. Within this role, the case manager/care coordinator is able to negotiate with multiple providers to obtain a variety of services.

As a process, CM/CC expands on the components of the nursing process: assessment, goal/outcome development, intervention, monitoring, and evaluation. The unique feature of CM/CC is that it is episode-focused and responds to care needs across multiple settings and disciplines.

As a service, CM/CC provides both facilitating and gate-keeping functions for the client. CM/CC has the ability to unravel the health care and social service delivery systems to the client’s best advantage. It can personalize care in an otherwise impersonal system and can take into consideration the client’s health status and diagnoses, treatment plans, payment resources, and health care options.

For purposes of this study, the perinatal care coordination system is defined as hospitals, managed-care organizations, community health centers and clinics, and public health nursing agencies. Due to budget limitations, private providers and clinics, as well as private home health care agencies,were not included in the survey.

Differences between the Medical Model and the Public Health Model

The Western allopathic medical approach generally has been characterized by its adherence to a model which diagnoses symptoms, relieves physical pain, and treats various diseases of the human condition, largely by isolating specific body parts, organs, or systems. It is a very effective model for dealing with critical illness (heart attacks, strokes, serious accidents) or contagious diseases (tuberculosis, measles, chicken pox) but much less effective in dealing with chronic illness (arthritis, diabetes, allergies, mental health conditions). Because of its emphasis on organs/body parts and disease, the medical model often fails to take into account the entire individual—particularly the social, emotional, and psychological aspects of the individual’s environment.

In contrast, the public health model is a much broader approach and, by its very definition, focuses on populations and the role of the individual (i.e., how the individual functions) in that population. Some of the distinguishing features of the public health model are its concern for informing the public about general health issues, its emphasis on prevention activities, the assessment and monitoring of population-based health problems, and the development, implementation, and evaluation of health promotion strategies (Lasker, 1997). As such, the public health model would appear to be a more appropriate and effective vehicle for addressing the broad, population-based health needs of low-income persons and their families, particularly after basic medical necessities have been met.

In undertaking this study of perinatal care coordination, the Perinatal Survey Team used a public health model of care coordination as a standard. Medical treatment alone cannot meet all of the social and behavioral challenges of caring for the high-risk pregnant woman. The social and behavioral risk factors identified during pregnancy should prompt appropriate interventions and support services. Because medical, psychological, and social risks often interact , a multidisciplinary strategy is required for successful intervention (Public Health Service Expert Panel on the Content of Prenatal Care, 1989).

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