Background/Summary: Maternal morbidity and mortality continues to rise in the United States. Between 2000 and 2014, there was a 26% increase in maternal mortality with 61% of maternal deaths occurring in the post-partum period. Evidence shows that maternal morbidity and mortality is still a concern several months after birth. Care for chronic maternal health conditions, lack of Interconception planning, and maternal support during the post-natal period is lacking in the United States system of healthcare. Unplanned pregnancies or shortened intervals between pregnancies have increased risk problems for both mothers and their babies. Research has shown that the healthier women are prior to pregnancy the greater likelihood of positive birth outcomes. In addition, planned pregnancies and adequate birth spacing has also increased positive birth outcomes. Using Long Acting Reversible Contraception (LARC) as birth control allows for greater likelihood of birth spacing and planned subsequent pregnancies. Managed Care Organizations/Health Plans can help bridge this gap by providing continuity of care through telephonic case management and support to women during the post-natal period. Women are the primary decision makers for themselves and their families when it comes to healthcare. A recent study found that 94% of women make decisions for themselves and 55% make decisions for others in their household regarding health. Telephonic Case Management can engage women and their families during the post-natal period to help promote Interconception care and continuity of care to increase positive birth outcomes for subsequent pregnancies as well as encouraging health promotion for the family.
UPMC is a world-renowned health care provider and insurer and the largest non-governmental employer in the state of Pennsylvania. They are a nonprofit that operates 40 academic, community and specialty hospital, 700 doctors’ offices and outpatient sites, and numerous rehabilitation, retirement, and long-term care facilities. The UPMC Insurance Division has case management teams that are comprised of Registered Nurses and Social Workers that provide support to members for their health needs. Case management during the pregnancy has been proven to improve birth outcomes. The Maternity Division of the Health Plan engages maternity members during their pregnancy and the post-partum period to provide education, support, and resources to members. After the post-partum period, members are encouraged to contact the Health Plan with any future needs or concerns. The current process is linear and focuses on the perinatal period.
Aim/Goal/Purpose: Optimize women’s health between pregnancies and promote birth spacing by connecting all women of childbearing age to health and lifestyle nurses/coaches at the Health Plan and increasing the use of LARC by implementing a process to facilitate referrals in the post-partum period.
Methods: This project consists of three phases: Phase I- Assessment, Phase II-Education, and Phase III-Evaluation of the Project.
Phase I: A confidential preliminary survey was sent to maternity team members to determine current knowledge of interconception care, morbidity and mortality data, and health and lifestyle programs offered by the Health Plan. Preliminary data was captured regarding whether maternity nurses and social workers were educating members on health and lifestyle programs and actively connecting members to a case manager or a health coach from July 2018 through September 2018. LARC claims data was also captured during that time.
Phase II: An educational session was provided to the maternity team which comprised of 26 maternity nurse care managers and one social worker in October 2018 which discussed the new workflow, rationale for the change in process, list of all health and lifestyle programs, background information on LARC, and mandatory educational modules on interconception care. Easy to read educational materials about interconception care and LARC were created for members of the Health Plan. Nursing assessments during perinatal case management were revised to include and document discussions of LARC during the third trimester of pregnancy and post-partum, birth spacing, chronic health conditions of women, and discussions/continued engagement by women after delivery with health and lifestyle coaches.
Phase III: UPMC reports were generated showing the specific case manager and number of referrals to case management and health and lifestyle programs. Claims data were collected on LARC insertions.
Results:
Phase I: From July 1, 2018 through September 30, 2018 UPMC received 2,234 delivery claims for newborn births. Of these claims, the following chronic conditions were listed for these women at the time of delivery: 54 Diabetes, 92 Hypertension, 73 Morbidly Obese, and 71 Tobacco Use. There were also 1291 visits for birth control during this time. The number of members who chose LARC for their birth control method was minimal at 263 (143 IUD, 120 Implant).
Twenty-four of the 27 maternity nurses case managers and social workers responded to a confidential survey. Survey results were assessed and knowledge gaps were determined. Knowledge gaps were found in the following areas: 20.83% unfamiliar with the definition of preconception care, 12% unfamiliar with the definition of continuity of care, 66% lacked understanding of why the U.S had made changes to the perinatal prevention program, 74% did not realize that preconception health should target both men and women of childbearing age, 33% were unfamiliar with the definition of Interconception period, 67% were unfamiliar with the ideal pregnancy interval, 55% were unfamiliar with the number of health and lifestyle programs that UPMC offers, and 29% were unfamiliar with LARC and optimal insertion time periods.
A report was generated to identify the number of health and lifestyle referrals conducted by maternity nurse case managers and social workers. From July 1, 2017 through June 30, 2018, 17 case managers referred members to 98 health and lifestyle programs.
Phase II: In October 2018, 26 maternity nurse case managers and one social worker successfully completed the training session. The training was well received by many. One nurse stated, “I enjoyed the presentation. There was so much information given! It really brought home the point that there is so much more that needs to be done for our post-partum mothers and there is so much more that we can do”.
Phase III: Data are currently being gathered on case manager specific referrals and LARC insertions in women receiving case management. Full results pending till conclusion of project on June 30, 2019.
Conclusion:
This project changed the workflow of the maternity team during the post-natal period to include a focus on Interconception planning and continuity of care. This initiative has the potential to improve birth outcomes for subsequent pregnancies and improve the overall health of the member. At the Health Plan, it is important that we continue to build on the relationships that we have already established with our maternity members while encouraging them to optimize their health and the health of their family.