One-to-one contact key to success of program
Case managers guide women through pregnancy
When pregnant Medicaid recipients find out about the Mom’s GEMS program offered by Horizon/Mercy, they’re often relieved that they have help negotiating the complicated health care system.
"The case managers tell about the sigh of relief that comes over the telephone when the members hear about the program. That’s worth everything. They are so thankful because they didn’t know where to go," says Pamela Persichilli, RNC, director of clinical operations for the Trenton, NJ-based managed care organization.
Members are recruited for the program through public agencies, referrals from other members, and physicians who notify Horizon/Mercy when one of their Medicaid patients comes in for prenatal care.
The physician fills out the Mom’s GEMS enrollment form and sends it to the insurer. Horizon/ Mercy uses the enrollment form for risk assessment. The data are entered into a database that stratifies pregnant members into risk categories.
The members are assigned to a case manager by the county in which they live, and the same case manager manages each member throughout the pregnancy.
"You need continuity between the case managers and members. If there are problems, the members know who to call," Persichilli says. Depending on the member’s risk factors, the case manager creates a plan of care for the pregnancy.
For instance, high-risk moms are those who have previous pre-term deliveries, gestational diabetes, adult onset diabetes, or who are expecting multiple births. The case manager is likely to contact them weekly or even daily to make sure they are getting the care they need.
Moderate risk factors include smoking and being on their feet all day.
Participants who are deemed "social risks" are those who have family or social barriers that could keep them from getting prenatal care. In these cases, the GEMS case manager works with the social work case manager to link the member to community programs that can help.
The case managers call members as often as necessary to establish rapport and make sure they are taking care of themselves.
If the members are high risk, the case managers are likely to call them daily until they understand what they need to do to coordinate their care, then weekly after that.
The case managers also conduct patient education over the telephone and in person when necessary, rather than relying on a set of printed documents that the member may not read.
If the members don’t show up for an appointment, they get a call from the case manager. The case managers help with whatever is necessary to get medical care for the members. In some cases, the social worker may arrange a home visit to work with the members. If a member is homeless, the social worker visits her at the hospital or in the physician’s office.
Communication isn’t limited to the members. "We talk to the doctors’ offices once or twice a week to make sure we’re meeting their needs," Persichilli says. n
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