Health plan helps at-risk expectant mothers
Executive Summary
A multidisciplinary team at CareSource, a Dayton, OH-based health plan, coordinates care for at-risk pregnant women and follows them for a year, or longer, after the birth.
• The team includes RN case managers, social workers, licensed practical nurses, and social workers.
• When women are identified for the program, an RN case manager with experience in prenatal care conducts a thorough assessment of medical and social needs and works with the women and their providers to develop a care plan.
• The team provides whatever support the women need throughout the pregnancy and after the birth.
Multidisciplinary team provides support
A multidisciplinary team at CareSource supports Medicaid members with high-risk pregnancies through the pregnancy and for as long as needed after the birth.
"We proactively identify members who need our support to make sure they are getting the services they need and to remove the barriers to prenatal care. We know that the earlier we can start supporting these moms, the better the outcomes," says Marcia Lange, RN, BSN, CCM, care management director of the Dayton, OH-based health plan.
Referrals come from providers, community agencies, and CareSource staff such as medical management and the health plan’s 24-hour nurse advice lines, as well as from the members themselves. The health plan also identifies members who are at high risk based on historical information such as problems with a prior pregnancy, chronic medical conditions that could affect the pregnancy, behavioral health issues, and social service needs.
Care for the pregnant members is coordinated by a multidisciplinary team that includes RN case managers, social workers, licensed practical nurses, and navigators who are non-clinicians but have experience in community settings and are familiar with resources in the community.
"We hired staff in communities across the state because we want them to be familiar with the challenges and the resources in the areas they serve," Lange says. The multidisciplinary team members spend most of their time in the field, at community agencies, clinics, and seeing members in their homes.
When members are identified for the program, a member of the multidisciplinary team calls them, explains the program, and enrolls members if they want to participate.
An RN case manager with experience in prenatal care conducts an extensive assessment, either in person or over the telephone. "The assessment covers everything about the member. It’s not just pregnancy-related, but includes other medical issues and social needs as well," Lange says. After the assessment, the case manager develops a care plan with input from the member and her providers. "The care plan focuses on what the member wants to work on and what is important to her," Lange says.
Components of the care plan may include managing blood sugar, obtaining supplies for the baby, transportation assistance, education on how to take their medications, nutritional advice, and reinforcing the importance of prenatal physician visits.
The interventions a member receives depend on her needs. If she has medical issues, the nurse works with her. The social worker steps in when the member needs community resources.
"The program is member-driven and depends on the needs of the mother and the baby. We tailor the care plan and the services and support to the member," Lange says.
In between visits and calls from the clinical staff, the navigators provide support and guidance to help the members navigate the healthcare system, Lange says. They may accompany the women to their physician visits if they don’t want to go alone, help them get food or clothing from local organizations, and remind them of their physician appointments and the importance of receiving regular medical care during pregnancy.
The case managers contact the members in the program at least once a month, depending on the members’ needs and preferences. A team member meets in person with the members at least every quarter, often more frequently, she says.
"The case manager gets back to the member as needed. If the woman is having urgent problems, the case manager may speak with her several times in one day. If her situation seems to be stable, the case manager may call just once every few weeks," Lange says.
The women are encouraged to have a home health visit when they go home after the baby is born. "Our team does a lot of educating to make sure the moms go to their post-partum visits and that they take their babies for well child visits. We call to remind them of the appointments and arrange transportation if needed," she says.
When infants are admitted to the neonatal intensive care unit (NICU), the nurse case manager contacts the mother to let her know that support is available and checks in with her periodically to answer questions and see if she needs anything. When the infants are about to be discharged from the NICU, the case managers go over the discharge instructions and medications, and help the parents understand how to use equipment such as monitors, oxygen, and suction equipment.
The team provides support for up to a year or longer, depending on the mother’s and baby’s needs. In some cases, the mothers may have been in high-risk case management before pregnancy and continue to need support. In other instances, the babies have complications and medical issues and the mothers need assistance in caring for them.
The mothers and case managers often forge long-lasting bonds. "Some of the women don’t have anyone else to turn to and they appreciate the support from the team," Lange says.
CareSource also has developed the Babies First program to encourage all pregnant women to see their providers for prenatal and postnatal visits. Participants receive a My CareSource Rewards gift card and can earn money on the card when they see their doctor during pregnancy and after delivery and when they take their children for well child visits. The health plan has partnered with local stores to allow the women to use the card for specific items such as baby supplies, first-aid products, family planning items, and nutritious food.
"The CareSource mission is to make a difference in the lives of the underserved by improving healthcare. These programs enable us to start early and help our members have healthy babies," Lange says.
