Problem Addressed

• A common problem: High-risk complications occur in 6 to 8 percent of all pregnancies.¹ Common factors for high-risk pregnancy include age (young or old); maternal weight (i.e., being overweight or underweight); preexisting maternal health conditions such as high blood pressure, diabetes, or human immunodeficiency virus; and previous pregnancy-related problems.²
• Negative health consequences: One common complication of high-risk pregnancies is a preterm delivery (defined as a baby born after less than 37 weeks gestation), which affects 12.8 percent of all births. These births often require time in a NICU, as the babies are not fully developed and need support and treatment.³ NICU admissions can be expensive and stressful for families.
• Lack of case management for this population: Case managers can help to reduce the risk of preterm delivery, but many case management programs do not focus specifically on this population. At Optima, for example, case managers saw patients with all types of chronic diseases but were not automatically assigned to high-risk pregnancies unless the woman had another condition (e.g., diabetes) that triggered assignment of a case manager.

Description of the Innovative Activity

• Identifying high-risk pregnancies: To identify patients who may be high-risk pregnancy candidates, case managers contact all female members of childbearing age to let them know about all of the services that Optima provides. If members indicate that they are pregnant, case managers proceed to tell members about the program. Optima also cultivates contacts with participating obstetric offices and uses member and provider newsletters and mailings to identify potential participants.
• Telephone-based case management: Case managers who are registered nurses contact high-risk pregnant members from a centralized telephone call center according to a predetermined schedule. During the calls, case managers follow a structured algorithm, asking specific questions about current health status and behavioral, psychosocial, and other medical issues. During the call, the case manager focuses on matching interventions to risk factors such as stress management, nutrition, access to health care, physical activity, lifestyle risk behavior, and medical risks.

  The telephone counselors seek to ensure coordination of prenatal care, provide education and support, create a network of support, and encourage self-care. Case managers try to help members with any issues that they may be having, and direct them to appropriate available resources to meet their health-related needs. If case managers cannot answer a specific question, they refer the woman to their health care provider, thus providing immediate reinforcement and leaving no question unanswered. Optima also helps to coordinate transportation services to appointments.

• Home visits: In collaboration with the Comprehensive Health Investment Project (CHIP) of Virginia (a nonprofit organization that provides family support systems throughout Virginia), Optima provides periodic home visits from registered nurses and/or community-based workers for women with major medical, psychosocial, or environmental risk factors. Through its six teams (covering six different areas of Virginia), the program conducts home visits at least once every 3 weeks. Over time, the community-based workers develop a relationship with the women, often getting to know them well enough that they know where to find them if they are not home at the time of a scheduled visit. The home visits create greater continuity and coordination of care, to reduce stress, and to encourage healthy behaviors. The field workers maintain regular contact with health plan–based case management staff.
• Monitoring database: Optima created a database that tracks statistics on key processes and outcomes over time, such as whether mothers fill their prescriptions for prenatal vitamins. The database allows physicians and Optima staff to monitor the program's impact and identify problem areas that need to be addressed.

References/Related Articles

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Innovator Disclosures

Results

• Reduced NICU utilization: Comparisons of program participants with a nonrandomized control group receiving usual care found that participants were less likely to have their babies admitted to the NICU (25 percent vs. less than 10 percent for program participants). In addition, the average NICU stay among the babies of program participants was 4 days shorter.
• Lower overall costs: The average number of NICU days for preterm deliveries fell from 15 days before program implementation to 13 days after the program was implemented. Total costs for the average infant's entire stay were approximately $5,000 lower. The total gross cost savings associated with this reduction was $2,368,853 between 2002 and 2004; net savings after subtracting program costs (not increased services) were $1,518,189.
• Improved health behaviors and more comprehensive prenatal care: Over one-fourth (27 percent) of program participants reported decreasing or stopping smoking during pregnancy. Program participants attended 88.5 percent of scheduled prenatal visits, while 81 percent of participants reported using stress management techniques.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Development team: An experienced team of case coordinators and case managers took the lead in developing the program, working in coordination with patient advisory representatives with extensive knowledge about health coaching.
• Use of existing framework: The team adopted an existing framework on how to organize services so as to manage the whole pregnancy (not just specific risk factors), including reducing stress levels and the risk of infection.
• Selection of measures: Since the data systems to measure health outcomes for preterm deliveries were not in place, Optima decided initially to use more readily available proxy measures such as NICU utilization/costs and the use of prenatal care. Tracking these indicators also helped demonstrate the value of the program to senior management because reduced NICU usage had the potential to reduce costs significantly.
• Hiring a contractor to provide home visits: Optima issued a request for proposals for the home visits, although relatively few agencies had experience in conducting such visits for pregnant women. CHIP, which had multiple sites throughout the state and experience in conducting home visits for children, won the contract, with initial funding coming from the Center for Health Care Strategies.
• Training: The March of Dimes helped to pay for training on how to conduct home visits for all CHIP team members.
• Pilot program: A pilot test of the program was conducted using grant money; the test found that the program generated significant cost savings, leading Optima leaders to make it a full-fledged initiative.

Resources Used and Skills Needed

• Staffing: Case management staff included registered nurses and community-based workers.

Funding Sources

Getting Started with This Innovation

• Identify a program champion: A strong leader is needed to oversee the relationships between the various departments in the health plan and outside agencies.
• Obtain senior leadership buy-in: Optima used a pilot test to demonstrate the business case for the program, which allowed program leaders to secure senior-level support.
• Develop or adopt a framework: A theoretical framework can be helpful in designing the key components of the case management program.

Sustaining This Innovation

• Continually monitor contracts with outside organizations: Contract changes with hospitals, physicians, and others may be needed during the course of the program.
• Hire experienced, qualified case managers: Case managers should enjoy working and interacting with pregnant women. The best case managers are able to develop strong bonds with their clients, often eliciting the sharing of information that is important to achieving positive outcomes.
• Establish a timeline with clients and caregivers: The case manager should work with the client and her physicians and nurses early in the pregnancy to establish a definitive timeline that covers the entire course of the pregnancy.

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