Premature birth is the leading cause of death in children under the age of five according to the March of Dimes. For the surviving infants and their families, the long-term complications and developmental delays are devastating. They are also costly for the nation. U.S. health officials have been fighting the prematurity rate on many fronts for many years and, though it has dropped from 12.3% (2003) to 11.4% (2013), it remains higher in the U.S. than in most developed
nations. The March of Dimes’ goal is 9.6% by 2020.
In 2012, the Department of Health and Human Services announced an initiative to reduce preterm births and improve outcomes for newborns and pregnant women. The Strong Start for Mothers and Newborns program, administered by the Centers for Medicare and Medicaid Innovation (CMMI) of the Centers for Medicare and Medicaid Services, has awarded approximately $41.4 million to 27 prenatal care providers in 30 states to serve a proposed 80,000 women. Strong Start’s two main goals are to reduce preterm births for at-risk Medicaid patients and to reduce the rate of early elective deliveries prior to 39 weeks gestation. Interventions are designed to not only meet the medical needs of the women, but also address the behavioral and psychosocial factors that affect their pregnancies. The 27 awardees are testing three kinds of interventions for enhanced prenatal care: centering/group visits, birth centers, and maternity care homes.
Dr. Scott Sullivan, Director of MUSC Health's Strong Start Program
Providers in South Carolina were awarded funding to test the maternity care home model throughout the state, where in 2013 one in seven babies (13%) was born before 37 weeks gestation. Scott A. Sullivan, M.D., Associate Professor of Obstetrics and Gynecology at MUSC Health, is the principal investigator for the $2.1 million four-year grant awarded in 2012 by CMMI to MUSC Health. The preterm birth rate among South Carolina Medicaid patients is high: 14% to 15%. For African American Medicaid patients, it is even higher: 16%. “And if you look at this population in the Pee Dee region, the rate is 19% to 20%,” says Sullivan. “The average gestation for African American Medicaid mothers in South Carolina is 35 weeks.”
These high-risk South Carolina women are the target population that is being cared for by Sullivan and a team of Maternal and Fetal Medicine (MFM) physicians and other prenatal care providers.
The maternity care home model is built on the patient-centered medical home, which offers care from a single clinician, continuous quality improvement, patient-centeredness, and timely access. The MUSC program begins with risk assessors screening the obstetric patients all over the state, identifying those who qualify for Strong Start, and referring them for the services. This high-intensity care management model is increasingly being used by organizations to cut the cost of treating the most complex patients. For example, Kaiser Permanente is creating high-risk clinics. In Kaiser’s Ohio region, the 1% of patients who accounted for 27% of total costs were referred to a high-risk clinic in which a team provided home care for about 150 patients. In a commentary in the October 15, 2009 New England Journal of Medicine, Bodenheimer and Berry-Millett note that these patients had fewer hospitalizations, fewer emergency room visits, and lower hospital expenses. These are early results and the numbers are small, but this model bears further watching as a cost-cutting measure.
Sullivan and three other physicians provide the MFM care in Charleston, Florence, and Beaufort, SC. Throughout the patients’ pregnancies and for ten weeks after, two nurse care navigators speak on the telephone with these patients as needed to answer medical questions and keep them on track to receive scheduled prenatal and postnatal care. When necessary, a social worker connects patients with appropriate resources. The program coordinator is Rebecca L. Timpner. “We’ve learned so much about how isolated, uneducated, and unsupported our patients feel,” says Timpner. “It’s staggering how big the problem is. The Medicaid system is difficult to navigate for most. With the added stressors of pregnancy and other medical and psychosocial issues, it’s hard for them.”
Sullivan says these patients’ socioeconomic stress factors are unbelievable. “Not having a home. Running from a partner. Not having heat, air conditioning, food, clothing. Moving from place to place. Now we know the reasons why a lot of our patients don’t come for their appointments or fill their prescriptions.”
Carolyn Nance, RN, and Tabor Hamilton, RN, are the two nurse care navigators who are equal parts medical advisor, mother, and life coach. Each handles about 150 to 200 patients at a given time. These nurses are available by phone 24/7 to answer medical questions and encourage prenatal care – no simple thing in this population that experiences so much insecurity.
Nance covers the state but primarily South Carolina’s Lowcountry and the Pee Dee. “The issues I treat range from diarrhea and breastfeeding to domestic violence, substance abuse, eviction notices, and no food,” she says. “One of my first patients had a previous addiction to cocaine. She had a heart attack, a stroke, kidney failure, had lost one baby. With the Strong Start program she delivered a healthy baby at 33 weeks, quit using cocaine, and has lost more than 150 pounds. Many times she called me during the pregnancy when she was tempted to do cocaine. I was able to reel her in. Her baby is now more than one year old. I’m still in contact with her. She sends me pictures.”
Nance estimates that she prevents at least three emergency room visits a week. “I do a lot of triaging over the phone,” she says. “I convince them that if they’ll call me back to talk about their back pain, for example, they don’t need to go to the ER.”
Hamilton’s patients are all over South Carolina. “A lot of these girls don’t have much family support at all,” she says. “Sometimes their parents are deceased or they are estranged from them. Sometimes their parents are in prison, all sorts of things. We provide a support system for them.”
Hamilton cites the 20-year-old patient who went to the ER every day (and made frequent false abduction claims to the police) because of what Hamilton eventually realized was a need for attention. “Her mother passed away when she was 12. She needed a lot of social support. Once I got her under my wing and she knew she could trust me, she just stopped going to the ER, stopped calling the police, and did well with her pregnancy.”
In August 2014, a social worker was added to the team. Sarah Friedrich, LMSW, connects patients with the resources they need, such as emergency housing, affordable housing, financial assistance, transportation, employment assistance, and assistance signing up for benefits. She also helps mothers obtain infant supplies and gain support through parenting and childbirth classes.
Sullivan says he’s learned that noncompliance is not necessarily a character flaw or recalcitrance. He cites the patient who would not take her insulin. Nance discovered that she had no permanent home, no transportation, and thus found it hard to get her prescription filled. Once Nance got her a place in a homeless shelter, arranged for transportation, and arranged for her to use the pharmacy at MUSC when she came for her prenatal care, she took her insulin regularly. “In the usual doctor’s office or clinic, we don’t screen people for those problems except at the opening visit and sometimes they don’t exist at the opening visit,” Sullivan says.
Timpner believes that the patients’ ability to text Nance and Hamilton at any hour, day or night, has been a huge part of the program’s success. “I think that kind of access is what keeps them from going to the ER,” she says.
At the conclusion of the grant in 2016, Strong Start sites will be reporting to CMMI on outcomes. These measures will include ER visits, total costs, length of hospital stay for mother and baby, total dollars spent in terms of pregnancy, regular prematurity rates, breastfeeding rates, and rates of prematurity: late preterm (34 to 36 weeks’ gestation), very preterm (less than 32 weeks) and very early preterm (28 weeks). Already, the MUSC site is able to document an increase in compliance for postpartum visits. Before Strong Start, 40% of patients returned for their postpartum appointment. Now the rate is closer to 70%, reports Sullivan.
Nance and Hamilton have several success stories of being able to extend the delivery date of complicated patients (some with preterm birth histories) by several weeks past 35 weeks.
In an evaluation of the program’s first year provided to CMMI, the Urban Institute reported that women being served by Strong Start thus far have lower than average Cesarean section rates, higher rates of breastfeeding, and in some cases, lower rates of preterm deliveries than the nation as a whole. For the full report, visit http://www.urban.org/research/publication/strong-start-mothers-and-newborns-evaluation/view/full_report.
While it is too early to make broad generalizations about the effects of Strong Start, these early data suggest some positive trends that merit attention as public and private health care officials work toward better birth outcomes for the nation’s youngest citizens.
In the larger health care environment, case management will not be adopted widely without changes in payment policy. For-profit hospitals will need to have an incentive to use effective hospital-to-home care management. Similarly, primary care practices are not likely to hire registered nurse care-managers if they are not reimbursed for that person’s work or don’t receive a share of the savings generated.
The Medicaid population in South Carolina is growing, says Sullivan. Programs such as Strong Start provide the kind of health care delivery innovation that is smart business and compassionate as well, as it gives mothers and the support they need to deliver a healthy baby.