2016 Mommy Steps Program Descriptions

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1 2016 Mommy Steps Program Descriptions Our mission is to improve the health and quality of life of our members

2 Mommy Steps Program Descriptions I. Purpose Passport Health Plan (Passport) has developed approaches to the management of members high risk obstetrical condition(s) in order in improve birth outcomes such as prematurity and low (LBW), and very low, birth weight (VLBW). The emphasis of the Mommy Steps Program is education for targeted members and clinicians to improve the overall health, wellness, and quality of the member s life. The Mommy Steps Program will facilitate member understanding and responsibility of the high risk pregnancy process as well as coordination of care between the member and/or caregiver and the clinician. The Mommy Steps Program focus is on increasing both member and clinician adherence with Passport Health Plan s (Passport) Perinatal Care Clinical Practice Guidelines which are based on the American College of Obstetricians and Gynecologist (ACOG) Guidelines. 1 II. Program Goals Increase percentage of members who receive prenatal care within 42 days of enrollment or within the first trimester. Increase average number of prenatal visits to 80% or greater of the expected visits per member to encourage regular prenatal care. Increase percentage of members who receive a postpartum clinician visit between 21 and 56 days after delivery. Decrease the number of preterm deliveries ( 37 weeks). Decrease the number of LBW (1,501 grams to < 2,500 grams) babies to 5% or less. Decrease the number of VLBW (< 1,500 grams) babies to 1% or less. III. Rationale 1. National According to the 2013 March of Dimes PeriStats, 11.4% of all live births in the United States were preterm, or 1 in 9. 2 In addition, 8.0% were LBW and 1.9% was VLBW Kentucky According to the 2013 March of Dimes PeriStats, 12.6% of live births in Kentucky were preterm, 8.9% were LBW and 2.2% was VLBW 3. Risk factors for LBW and VLBW include smoking, alcohol, street drugs, and abusing prescription drugs, little education, low income, being unemployed, age, race and/or ethnicity May 10, 2016 Page 1 of8

3 Major risk factors for preterm birth include a history of preterm birth, current multiple gestation pregnancy, some uterine/cervical abnormalities, infection (especially genito-urinary), diabetes mellitus, hypertension, late or no prenatal care, smoking, alcohol, and illicit drug use Passport In 2015, Passport had an average of 2,451 per quarter enrolled in the Mommy Steps Program, with an average of 1,163 per quarter new members, a 15% increase from There was an average of 614 members per quarter identified as high risk based upon the Mommy Steps Program s stratification criteria, a 56% increase from An average of 444 high risk members per quarter was actively engaged and received one-onone telephonic contact and educational materials from a High Risk OB Case Manager, a 64% increase from There was an average of 386 members per quarter who received postpartum outreach calls, a 49% increase from An average of 591 referrals per quarter was made to WIC, HANDS and Healthy Start, a 44% increase from New members received individual educational mailings. The Mommy Steps High Risk OB Case Managers collaborated with Utilization Management (UM) OB Embedded Case Managers to ensure members needs and resources were provided. Population Impacted: Population (US) 2 Population (KY) Population (Passport) % of total membership % preterm live births 8.0% low birth weight (LBW) 1.9% very low birth weight (VLBW) 12.6% preterm live births 8.9% LBW 2.2% VLBW 11.6% preterm live births 6.7% LBW 1.2% VLBW Utilization/Cost: Utilization/ cost (US) 4.2 mil inpt admits, $16.1 bil (2008) 4 Utilization/ cost (KY) 57,791 inpt admits, $30 mil (2011) 5 Emergency Room (ER) Utilization/ cost (Passport- 2015)** 6,186 visits/ $2,055, Inpatient (IP) Admissions/ cost (Passport- 2015) 7,032 admits/ $29,983, Day Readmit (Passport-2015) 389 readmits/ $1,855, Total Members in Program (Passport- 2015) 6,500 **All members who received prenatal care and had a delivery for 2015 regardless of time with Passport. ER and IP only apply to the prenatal period prior to delivery date in claims Referenced under rationale in each appendices 3 The figures reflect better outcomes because rates were modified due to the exclusion of miscarriages and stillbirths from the collected data. 4 https://www.hcup-us.ahrq.gov/reports/statbriefs/sb110.jsp 5 https://prd.chfs.ky.gov/monahrq/2012/monahrq/util/std/agg/mdc_all.html May 10, 2016 Page 2 of8

4 Ability to impact birth outcomes: Potential areas of impact (in addition to a reduction in healthcare costs) Education of pregnant members during pregnancy and post-pregnancy increase the rate of deliveries at 37 weeks gestation, increase the frequency of prenatal visits for gestational age ensuring members receive adequate prenatal care, increase frequency of postpartum visits to prevent postpartum complications, reduce the rate of LBW and VLBW infants, decrease the frequency of elective delivery at < 39 weeks gestation, decrease smoking rates and the rate of maternal and infant postpartum readmissions, and improve the quality of life of members. IV. Member Participation and Opting Out Eligible members are considered enrolled in the Mommy Steps Program and receive interventions without having to specifically request it. For this reason enrollment is considered passive. Participation, however, is voluntary and the member has the right to opt out of the Mommy Steps Program or decline all or any part of it. Information on how to opt out is provided as part of the welcome packet and the member is advised verbally if questions regarding participation arise during outreach. Members who opt out may re-enter the Mommy Steps Program at any time by contacting the High Risk OB Case Manager or the Care Connection Program, either verbally or in writing. V. Integrating Member Information Passport utilizes Identifi, an integrated medical management technology platform, in order to allow all health plan staff access to member information. In Identifi, all users are able to view information that is specific to the member such as demographics, eligibility, member s clinician, spoken language, and preferences on receiving educational materials or phone contact. Users also have the ability to enter additional addresses or phone numbers, which the member may give as an alternative way to reach him/her that is not associated with the state file download that populates the basic demographic fields in Identifi. The Patient View may be utilized to denote a caregiver name and phone number, as needed. In addition, Identifi users can perform the following activities: Edit demographic information and preferences, as needed. Upload documents related to the member and/or the member s care that need to be visible to all users in order to facilitate seamless care coordination. View all the documentation that has been entered as it relates to the member. View any correspondence that the member has sent to Passport, or that Passport has sent to the member. View the member s established care coordination assessment and plan of care. View claims, both pharmacy and medical, related to the member. View results of labs/screenings, as available. View a clinical summary/history of the last six months of the member including tests and services, medical conditions, medications, ER visits, IP admissions, office visits, etc. View historical data or closed cases. May 10, 2016 Page 3 of8

5 All of this data allows everyone interacting with the member to have the most current and available data in order to make every member contact count to its fullest potential and improve coordination of care by all users having the same information. VI. Population Identification Eligible members for the Mommy Steps Program are identified primarily through clinician notification of pregnancy to Passport but can include the following: Data collected through the UM process, examples include, but are not limited to, hospital census report, ER Utilization reports, and embedded UM Data collected through the Care Connection Program health and wellness outreach representatives Referrals from clinicians This includes, but is not limited to, OB clinicians, Departments of Health (DOH), and Teen Pregnancy programs Referrals from other Passport departments, examples include, but are not limited to, Case Management (CM), Disease Management (DM), EPSDT, Member Services, or Stork Care Referrals from subcontractors This includes, but is not limited to, 24/7 Nurse Health Information Line Self-referrals from members Referrals from hospital educators/discharge planners Data collected through the Health Risk Assessment Form (HRA) Data collected through the weekly Pregnancy Report (PRG) Members who meet the criteria are eligible for the Mommy Steps Program. This determination of eligible members occurs on a daily basis. In addition to identifying members on a daily basis, members may be adjusted from low risk to high risk. Program Participation Requirements: Continuous Age Diagnosis enrollment Utilization Pharmacological All pregnant members Pregnancy All enrolled pregnant members N/A N/A May 10, 2016 Page 4 of8

6 VII. Member Contact Eligible members are identified weekly and receive a welcome packet including: Welcome letter (Appendix A), and Information on: o The importance of early and regular prenatal care o Community resources such as WIC, HANDS, Healthy Start o Text4Baby Program o Smoking cessation resources o Available treatment for drugs and alcohol, mental health services o Domestic violence support line o Dental and vision service contacts o Legal assistance contacts o Support group information for loss of an infant o State transportation service contact numbers o Member incentives The welcome letter encourages the member who wants to participate in the Mommy Steps Program to call Passport to receive the March of Dimes Month by Month Book. Members who call Passport are screened for any high risk conditions that could result in poor birth outcomes, demographics are verified, and members are given the Care Connector Program contact numbers to call with any questions or if anything changes during the member s pregnancy. In addition, the members receive: Assistance with rescheduling missed OB appointments and overcoming barriers that may contribute to further missed appointments, such as transportation and language barriers. Postpartum telephonic outreaches to screen for postpartum complications, educate on the importance of scheduling a postpartum visit, newborn visits, assist with newborn enrollment with Medicaid and Passport, other available resources, and answer any questions. Annual reminders are sent for flu/pneumonia vaccination. All identified pregnant members with any of the following will be considered high risk (Appendix B): Substance Abuse Homelessness Domestic Violence Teen Pregnancy (18 years and younger) Chronic Hypertension (CHTN) Diabetes (Type 1, Type 2 and/or Gestational Diabetes (GDM)) History of Pre-term Delivery (<37 weeks) Triage (for Mommy Steps Team only) Pregnant members identified as high risk receive outreach from a High Risk OB Case Manager. The High Risk OB Case Manager: Assesses the member s needs utilizing a maternity-specific assessment. May 10, 2016 Page 5 of8

7 Coordinates care with the clinician involved in the member s care. Establishes and maintains contact with the member to evaluate and revise the plan of care as needed. Educates the member and/or caregiver on the importance of medication adherence, attending scheduled appointments, adherence with self-monitoring activities, and adherence with screenings/lab tests. Educates the member and/or caregiver on lifestyle changes that may improve the member s birth outcome such as diet/weight management, medication adherence, exercise, smoking cessation, avoidance of drugs and alcohol, and regular clinicians visits. Outreach to members continues throughout eight weeks postpartum. Conducts the Patient Health Questionnaire (PHQ) 2 at postpartum as a depression prescreening tool and based on the results, completes the Edinburgh Postnatal Depression Scale (EPDS) Assessment, to identify members in need of referral for behavioral health services. Provides the member with assistance/information regarding available community resources. Provides the member and/or caregiver with additional written and/or verbal information targeted to the member s specific diagnoses. VIII. Clinician Notification and Involvement Participating clinicians in the health plan are notified of the Mommy Steps Program by the following: Quick Reference Guide distributed to new clinicians with information regarding how the High Risk OB Case Manager works with pregnant members and instructions on how to access and utilize the program services (Appendix C) The Passport Provider Manual The Passport Provider e News Clinician outreach visits by the Provider Relations Department and/or High Risk OB Case Manager Passport s Perinatal Care Clinical Practice Guidelines which are based on the ACOG Guidelines are available to all participating clinicians. Guidelines are reviewed and updated at least every two years and anytime new scientific evidence is published. IX. Member Satisfaction with the Mommy Steps Program Passport s Mommy Steps Program has a systematic method of evaluating member satisfaction with all areas of maternity services. A Satisfaction Survey is distributed to all pregnant members after one successful contact. Questions address member experiences with the Mommy Steps Program and the High Risk OB Case Manager in the areas of: The effectiveness in helping the member understanding high risk pregnancy. The helpfulness in assisting the member developing a self-management plan. The helpfulness in assisting the member adhering with the established self-management plan. The usefulness of the educational materials provided. May 10, 2016 Page 6 of8

8 The ability of the High Risk OB Case Manager to listen to the member. The helpfulness of the High Risk OB Case Manager to assist the member in care coordination. Complaints regarding the Mommy Steps Program may also be received by the Member Services Department during routine member contacts. The Member Service staff document the complaint in EXP, a customer service software package that records, tracks, and reports all member inquiries and/or complaints. Each department has a mailbox specific to the department. Member Services forwards the EXP complaint to the Manager of High Risk Maternity Management for follow-up. The Manager of High Risk Maternity Management conducts a quantitative and qualitative analysis of complaints regarding the Mommy Steps Program annually. This analysis is used to identify patterns of member complaints and opportunities to improve satisfaction with the Mommy Steps Program. Changes to the Mommy Steps Program are made as needed. X. Annual Evaluation The annual evaluation of the Mommy Steps Program is conducted by Passport s High Risk OB Case Managers, the Manager of the High Risk Maternity Program, the Director of Medical Management Care Coordination, the Medical Director of Women s Health, the Director of Quality, and the Chief Medical Officer, or designee. Objectives, activities and outcomes are evaluated at a minimum of annually in order to: Measure participation rates. Determine whether the Mommy Steps Program has demonstrated improvement in birth outcomes and quality of care provided to pregnant members. Evaluate the overall effectiveness of the Mommy Steps Program. Allow for exploration of barriers and limitations of the Mommy Steps Program. Revise areas as needed to improve effectiveness of the Mommy Steps Program. Formal measurements of Frequency of Ongoing Prenatal Care, Initiation of Prenatal Care and Postpartum Care are performed annually through HEDIS 1 reviews using HEDIS methodology. Program goals for LBW, VLBW, and Preterm Births are based on Healthy People 2020 and are measured on delivery information obtained through facility notification of delivery. Results are utilized to revise the program and set the program goals for the following year. More frequent barrier analyses are performed on an ongoing basis and adjustments to the Mommy Steps Program are made accordingly. Final approval by the Quality Medical Management Committee: May 6, 2014 August 14, HEDIS is a registered trademark of the National Committee of Quality Assurance (NCQA). May 10, 2016 Page 7 of8

9 Appendices A. Welcome Letter B. High Risk Stratification Tool C. Satisfaction Survey

10 Member Welcome Letter Appendix A

11 Member Welcome Letter Appendix A

12 Member Welcome Letter Appendix A

13 Member Welcome Letter Appendix A

14 Member Welcome Letter Appendix A

15 Member Welcome Letter Appendix A

16 Member Welcome Letter Appendix A

17 Member Welcome Letter Appendix A

18 High Risk Stratification Tool Appendix B

19 Satisfaction Survey Appendix C

20 Satisfaction Survey Appendix C

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