Prenatal program slashes premature birth rate
Members are rewarded for participating
Strategies such as rewarding pregnant women for keeping their appointments with physicians, and making it easier for physicians to file claims, have paid off for Horizon/Mercy’s Mom’s GEMS (Getting Early Maternity Services) prenatal program.
Horizon/Mercy, headquartered in Trenton, NJ, covers 273,021 members, representing 42% of the state’s total managed care market for the publicly insured. The health plan members have approximately 6,000 deliveries a year.
The Mom’s GEMS program was begun as a response to an increase in pre-term births in New Jersey and a high African-American infant mortality rate.
"We needed a way to get our moms into care and keep them in care. The Medicaid world is very different from the commercial insurance world. Our moms need someone they can reach out to, someone who can answer questions and help them advocate for themselves," says Pamela Persichilli, RNC, director of clinical operations for Horizon/Mercy.
The company’s efforts to provide high-quality services to the publicly insured was recognized in a best practices report on Medicaid managed care called Innovations in Medicaid Managed Care: Health Plan Programs to Improve the Health and Well-being of Medicaid Beneficiaries by the American Association of Health Plans (AAHP). Five Horizon/Mercy programs, including the Mom’s GEMS program, were profiled in the national report.
Members in the Mom’s GEMS program receive frequent contact from case managers throughout their pregnancy. The medical case managers work with Horizon/Mercy’s social work case managers and community agencies to help the women find housing, food, and transportation to and from the physician’s office.
The program has reduced the number of premature babies among members while achieving cost savings.
From August 1999 through January 2000, only 5% of the Mom’s GEMS program members had premature babies, compared to 13% of the plan’s non-GEMS members. The GEMS program babies spent a total of 394 days in the neonatal intensive care program, compared to 529 for the babies of mothers not in the program.
The improvement has continued, Persichilli adds. For moms in the Mom’s GEMS program, the low first weight for the first quarter of 2002 was 2.06 per thousand deliveries. Very low birth-weight babies made up only 0.44 per thousand deliveries.
The Horizon/Mercy staff hit on the incentive program as a way to ensure that the expectant mothers receive proper prenatal care. "We were looking for ways to make everybody happy with this program — to get the moms to participate, and to recognize the provider needs," Persichilli says.
Physicians who enroll their Medicaid patients covered by Horizon/Mercy into the Mom’s GEMS program are assigned an authorization number that covers all claims for prenatal care, delivery, and postpartum care. There is no need for the physician to get further authorization to treat the patient.
When a member keeps an appointment with her physician, she receives an incentive gift. Among the gifts she receives are a diaper bag, a hooded baby towel, a "mom’s pack" filled with lotions and toiletries, and a baby camera.
"After each visit, something comes in the mail for their diaper bag we sent at the beginning. It’s a really nice way of reminding them that they did great by keeping their appointment," Persichilli says.
The case managers work with the social workers and local agencies to make sure that the pregnant women have everything they need during the pregnancy and that all barriers to good care are eliminated.
For instance, if a member doesn’t have access to a telephone in her home, Horizon/Mercy provides her with a pre-programmed cell phone that she can use to call the case managers, the provider, the hospital, and a family member, such as a mother or a sister. The phone is programmed so it can be used only for calls to and from telephone numbers of people the member may need to contact.
The case managers arrange transportation for the members to keep their medical appointments and may work with local agencies to see that the mother-to-be gets food stamps.
"Transportation is often a major barrier for the pregnant moms, and if a mom can’t put food on the table, she’s not likely to worry about herself. We work to reduce any barriers to a healthy pregnancy," Persichilli adds.
The members also receive informational packets each trimester. The packets are geared toward the members’ risk factors and may include information on smoking cessation, the danger of using drugs or alcohol during pregnancy, tips for staying healthy during pregnancy, breastfeeding, postpartum care, and information about pediatric care.
All of the mailings are geared to the educational level of the recipients.
Case managers also may help mothers with high-risk pregnancies negotiate the health care maze. For instance, if a woman is referred to a perinatologist, the case manager makes sure she goes to one that is near her home. If mothers need more intense work-ups, the case manager works with local centers of excellence for maternal and child care to meet their needs.
The members frequently call their case managers to report on their office visit and with questions.
After delivery, the mothers continue to participate in the Children’s Health Assessment and Preventative Services (CHAMPS) program, an offshoot of Mom’s GEMS that covers children from birth through age 2.
After a year, the CHAMPS program has increased well-child visits by 16%.
The program is so popular with the members that they often refer their sisters or friends to the case managers for help, giving the program another referral source.
Horizon/Mercy’s marketing and communications departments educates providers and people in the community to get word to all eligible mothers to be that the program is available.
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