Preterm Labor: Enhancing Assessment Competency and Reducing Variation among Telephonic Maternity Care Managers in a Managed Care Organization

Introduction/ Background: Preterm labor is a major public health issue that has substantial direct and indirect costs including staggering health care costs from prolonged neonatal intensive care unit (NICU) hospitalization; potential long-term health consequences such as cerebral palsy, mental retardation and blindness that can impact overall quality of life; and significant emotional costs for the family from increased levels of stress and potential loss of income. More than 50% of preterm births occur among women with no identifiable risk factors. It is essential that pregnant women be assessed for actual and potential risk factors and educated about their risk status, signs and symptoms of preterm labor, and the importance of early medical intervention. The UPMC Health Plan, a part of the UPMC Health System, is a regional managed care organization located in Pittsburgh, PA. The UPMC Health Plan shares a common set of values with the rest of the system to create a consistent UPMC experience across the continuum for the patients, health plan members, employees, and the communities it serves. A telephonic maternity care management program is available for pregnant members with commercial health insurance, as well as members enrolled in government programs such as Medical Assistance. The program is staffed by thirteen registered nurses with extensive obstetrical nursing experience functioning in the role of maternity care managers. The maternity care manager contacts the member by telephone, completes a comprehensive assessment, and offers prenatal and postpartum education. The average caseload per nurse is 185 members.   

Purpose:  The purposes of this project were to develop a preterm labor competency assessment to identify gaps in existing knowledge and assess the comfort level of thirteen  registered nurses in the maternity  program working telephonically with pregnant women whom may experience preterm labor during their pregnancy,  to develop a  preterm labor learning module using current evidence-based research and practice guidelines, and  to devise a standardized care pathway to ensure consistency of risk assessment and education provided to UPMC Health Plan members enrolled in the telephonic maternity care management program.

Methods: Through the Sigma Theta Tau International (STTI) Maternal-Child Health (MCH) Nurse Leadership Academy, sponsored by Johnson & Johnson, this fellow ; Laura Fennimore, the leadership mentor; and Catherine Burns, the STTI MCH faculty advisor, participated in a faculty guided leadership and mentorship program to acquire and enhance leadership skills necessary to facilitate a quality improvement project focused on improving maternal-child outcomes.  The Fellow used a team of nine healthcare professionals that consisted of maternity nurse case managers, hospital-based nurses, physicians, and project analysts to help develop the project using a Logic Model framework. Team members conducted a review of literature and current practice guidelines for preterm labor related to risk factors, diagnosis, treatment and pertinent patient education to develop staff education content.  A PowerPoint presentation was developed and presented to maternity staff along with a preterm labor resource packet.  In addition, the team is developing a standardized preterm labor care pathway to be utilized by all maternity care managers to help reduce variation in assessment of risk and improve pregnancy outcomes.

A number of evaluation strategies were used to evaluate the success of the project. A pre/post-education survey using a five point Likert scale was developed and provided to all maternity care managers to assess their overall comfort level related to preterm labor management and caring for women experiencing this pregnancy complication. Since all calls with members are recorded, a call and chart audit tool was developed t o evaluate change in care manager behavior related to risk assessment of preterm labor and the consistency of patient education provided pre-education and post-education. Audits are planned for 3 month intervals to determine the extent of nurse behavior change and if change was sustained over time. Constructive feedback and coaching is provided to staff members as needed. The data analysis will include individual and group results.  Maternity assessments utilized by the maternity care managers will be revised to improve assessment of risk and identify opportunities for patient education. 

Results: The pre and post education surveys of the nurse case managers showed improvement in their overall comfort level of nursing care for pregnant women experiencing preterm labor. The mean overall comfort level on the pre-education survey of 4 increased to 4.6 on the post-education survey and an increase of 24% indicating feeling extremely comfortable.  All of the nurse case managers indicated that they were extremely likely to incorporate the information provided into nursing practice and 70% rated their comfort level regarding their role as case manager caring for this population as extremely comfortable. The pre- education and post- education call and chart audits results are still being collected and evaluated. Findings will be reported at a later date.  Calls and charts audited at the following intervals; pre-education and post-education. Constructive feedback is provided to maternity case managers as individuals and as a group on an ongoing basis to ensure staff remains competent. The electronic medical record template for maternity assessments has been redesigned to enhance risk assessment.

Conclusions: The project found that prior to the intervention there was significant variation among the care managers in the assessment of preterm labor risk and patient education provided.  In addition, the information provided to members was not consistent with current evidence based practice guidelines.  Following the education program, utilization of the written module, use of the improved EMR template, feedback from call and chart audits, and development of a standardized care pathway, the expectation is improved consistency of risk assessment and education provided by the maternity case managers to pregnant women enrolled in the telephonic maternity care management program at UPMC Health Plan.   Additionally, the project provided a vehicle for discussions with a variety of obstetrical providers including private and outpatient clinic obstetric practices and the inpatient hospital staff to look at provision of system wide best practices to educate pregnant patients about preterm labor risk factors, reduction and prevention of risks, and early identification of preterm labor to minimize risks and enhance pregnancy outcomes.

As a fellow in the STTI MCH Nurse Leadership Academy, the fellow has learned to apply the five Kouzes and Posner leadership principles to her role as manager of the UPMC Health Plan Maternity Program. The fellow models the way through her commitment to the highest standards for professionalism and personal integrity in her daily work with her team and makes exceeding expectations a priority. In the past few months, she has worked closely with her director to inspire a shared vision and challenge the process for changes within the maternity program as the team strives to improve efficiency and effectiveness, and improve member engagement levels. The fellow has enabled others to act by engaging staff in various aspects of this project by involving them in the research for current evidence based practices and the development of preterm labor course content. Staff were also included in the decision making process which helped to facilitate the successful adoption of program changes by the team. The fellow encourages the heart of her team members by actively listening to the personal concerns of her staff, celebrating their personal and professional milestones, and by promoting the maternity program to medical directors, other departments, and to the OB provider community.