FALLING THROUGH THE CRACKS: Findings

Thirty-two (32) of 38 organizations responded to the survey, including 15 of the 18 community health centers, all three agencies providing public health nursing services in the two counties, all five health plans, and 9 of 12 hospitals in the Twin Cities metro area. This constitutes an overall response rate of 84%. The following is a summary of findings across all categories of agencies/organizations, outlined according to the four topic areas included in the survey. (See Appendix 5 for detailed responses categorized by type of respondent.)

Mission and Scope of Practice

The traditional safety net organizations—the community health centers and public health nursing agencies—all had mission statements describing their commitment to serve low-income, underserved populations including immigrants, refugees, and the uninsured. Pregnant women and infants were regarded as particularly vulnerable populations requiring outreach activities to assure early, ongoing prenatal care and including an array of additional supportive services requiring formal collaborations among many organizations. The added time and cost required to serve non-English speaking populations was often mentioned.

Health plans’ mission statements implied that they exist within a competitive environment and strive to be the plan of choice in the community they serve. Their mission statements described the desire for excellence and the need to be recognized as leaders in improving their members’ health.

Hospitals were not asked to provide a mission statement.

“Our public health staff build on family-focused, community-based principles in delivering services to perinatal clients. Staff are skilled in
working with families
who have complex social
needs and use multiple
resources in the community to help meet those needs. Staff are also able to address sensitive family issues such as chemical use, violence, and other
complex situations. The
focus is on prevention and early intervention.”

Public Health Nursing Director
 

Community and Systems-Level Activities

Community health centers described their attempts to provide a model of health care to low-income patients that involved advocacy to improve patients’ access to medical care and supportive services, including outreach in the community served. Additional community-level activities included networking with other community-based organizations and participation in community events.

Public health nursing agencies emphasized coalition building and collaboration, particularly around a common,health-related purpose. Most coalitions involved other public health organizations, although some involved partnering with health care and managed care organizations. Collaboratives were formed to share information and resources, as well as to develop policy and advocacy strategies for health-related community issues. Examples are lead-poisoning prevention, violence-free families and communities, child abuse prevention, and child injury prevention. Family Service Collaboratives were listed as partners, as were schools and social service providers.

In responding to this survey topic, health plans and hospitals described their case management programs. Except for one health plan, they reported that their case managers interact and coordinate care among providers as opposed to having regular contact with patients. The reason noted was to minimize confusion for patients. When contact was made with patients, it was almost always made by phone or letter.

All health plans and hospitals reported offering some level of referral to social services. Coordination of follow-up for social issues addressed in prenatal assessment varied widely. One health plan and one hospital had comprehensive referral links and significant administrative capacity for this type of activity. Overall, however, the hospitals and health plans reported using care coordination standards and processes designed primarily to identify and respond to medical risk factors.

Great variation exists among health plans regarding the degree to which system capabilities addressing social risk factors are integrated into their processes. When social risk factors are addressed by case managers, it is done by telephone as opposed to in-person contact. One hospital and one health plan serving specifically high-risk, low income populations reported having more extensive organizational structures and procedures in place to provide perinatal care coordination, including regular use of public health nurses to coordinate the care of prenatal patients.

Client-Level Activities

Community health centers/clinics reported providing primary health care to women and children, including medical care, prenatal and postpartum care, newborn and well/sick child care, and family planning. All fifteen survey respondents also provide supportive services including assistance with insurance applications, assessment, treatment and/or referral for psychosocial issues. All described how they have developed competencies to address the sociocultural needs of the diverse populations they serve.

The three public health nursing agencies described their processes of developing care plans and goals with families’ input. They reported that they provide all of the survey components of health teaching, brief counseling, and care coordination/case management. They also discussed their limited ability to monitor patient outcomes, given their current systems. At the time of the survey (May-June, 1999), all three were using paper records. Two of the three agencies used random chart audits to determine whether preset goals were met.

The hospital survey, as previously described, asked questions about specific areas considered a problem in the infant mortality review project. As applied to care coordination, the questions concerned with discharge planning and obtaining information from prenatal providers were most relevant. All hospital respondents reported that discharge planning includes informing new mothers about conditions needing immediate medical follow-up and, at minimum, the provision of a phone number for them to call. Other post discharge procedures ranged from referral to home health care, a public health nurse visit, or breastfeeding clinics, to social worker follow-up for families with complex social and behavioral issues.

Four of the five health plans reported having incentive programs to encourage their PMAP patients to keep prenatal appointments and/or attend prenatal classes. Three plans provide written materials to their PMAP patients in the form of a pregnancy information and resource packet. Four plans discussed how assessment of risk factors prompted mail or phone follow-up with specific education materials or phone line resources. Two of these four health plans also reported referring high-risk patients to public health nurses; one refers patients to a community-based organization with family resource workers who have access to advice from a public health nurse consultant. The remaining two health plans reported managing risk factors by phone and/or mail contact only.

Agencies reported that care coordination activities which take place during pregnancy—or for infants and children—are not
reimbursed by health plans or by the Minnesota Medicaid
Program.
 

Financial and Capacity Issues

Reduced federal funding combined with increased costs of providing services and poor third-party reimbursement levels have community health centers feeling financially strapped. They reported finding it increasingly difficult to provide “wrap-around” services on site. At the same time, some centers are aware that referring their patients to other agencies may not be effective because of the difficulties families have following through with referrals. They listed missed appointments for clinic services as a source of financial loss. Their attempts to provide continuity and comprehensive health care are often made more difficult by patients who are taken on and off health plans as the family’s economic status changes. For example, a managed care plan reported that four months is the average length of time that PMAP patients are enrolled in their plan. By contrast, a health care center assumes responsibility for continuous patient care as determined by individual patient needs, which typically exceeds four months.

In the context of this report, prenatal/postpartum and infant care requires a commitment of at least one to two years. Most of the community health centers who adhere to this commitment end up providing services that are not fully reimbursed or that require reimbursement from multiple payors for one pregnancy, adding greatly to their administrative costs. Health centers also reported seeing more uninsured patients than in previous years, with incomes insufficient to pay the sliding fees. Insurability is a problem particularly for the growing Latino population. Many Latina women are reluctant to pursue insurance coverage either for themselves or members of their family due to uncertain immigration status.

When asked for recommendations to deal with the foregoing issues, community health centers emphasized the need for financial support to improve technology and data capacity, additional funding for patient outreach and supportive services, and stable funding for their basic programs and infrastructure.

Public health nurse agencies reported both funding and capacity issues. These agencies are unable to do effective public health outreach and in fact have difficulty serving the number of patients referred to them. Fifteen to twenty percent of their attempted home visits are not completed because the client is not at home when the nurse arrives; these visits are not reimbursable. Meanwhile, agencies reported that reimbursement rates from Medical Assistance and PMAPs have not kept pace with the escalating costs of providing professional services. Moreover, obtaining authorization for third party reimbursement is complex and time consuming. Agencies also reported that care coordination activities which take place during pregnancy—or for infants and children—are not reimbursed by health plans or by the Minnesota Medicaid Program.

Survey respondents from the health plans did not report data on financial and capacity issues. Presumably, staff did not have adequate knowledge of their respective plan’s financial status. Although the survey team did not make additional inquiries for financial data from the plans themselves, health plan financial information was obtained from other sources and is included in the Discussion section of this report.

For complete survey findings, including specific recommendations provided by each group of survey respondents, see Appendix 5.

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