2019 Mommy Steps Program Evaluation...The Mommy Steps Program (Program) is designed to improve...

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2019 Mommy Steps

Program Evaluation

2019 Mommy Steps Program Evaluation

Table of Contents

Program Purpose Page 1

Program Goals and Objectives Page 1

Measurements Page 1

Evaluation

Annual Participation Rates

Birth Outcomes and Healthy People Goals vs. Passport Health Plan’s Corporate Goals Pages 2-4

Maternity Management HEDIS® Results Pages 4-5

Healthy Kentuckian Results Pages 5-8

Analysis of Findings Page 9

Maternity Members by Age Groups Page 10

Total Deliveries by Type Page 11

Emergency, Admission and Readmission Utilization Page 12

Maternity Cost Trends Page 13

Overall Financial Impact for Identified Sample of Maternity Members Page 14

Member Satisfaction Survey Results with Services Received Page 15

Barriers/Opportunities Pages 16-17

Activities Pages 18-22

3/3/20 FINAL Page 1 of 22

2019 Mommy Steps Program Evaluation

1 “Medicare Direct Contracting for Disease Management.” Disease Management Association of America, March 2003 2 The source for data contained in this publication is Quality Compass® 2019 (Medicaid) and is used with the permission of the NCQA. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA.

Program Title: Mommy Steps Program

Evaluation Period: January 1, 2019 – December 31, 2019

Program Purpose: The Mommy Steps Program (Program) is designed to improve prenatal, infant, and maternal outcomes through improved compliance of both Obstetric (OB) providers and members with Passport Health Plan’s (Passport) Perinatal Care Clinical Practice Guidelines, which are based on the American College of Obstetricians and Gynecologists (ACOG) Guidelines. Perinatal Management is the process of coordinating health care interventions and communications for pregnant members and recently delivered members in which patient self-care efforts are significant, supporting OB providers/member relationships and the plan of care; emphasizing prevention of complications by providing support and care coordination to increase compliance with Passport’s Perinatal Care Clinical Practice Guidelines utilizing patient empowerment strategies; and evaluating clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health.1

Program Goals and

Objectives: • Increase percentage of members who:

o Receive prenatal care within 42 days of enrollment or within the first trimester.

o Receive a postpartum visit from an OB provider between 21 and 56 days after delivery.

• Increase the average number of prenatal visits to 80% or greater of the expected visits per member to encourage regular prenatal care.

• Decrease the number of: o Preterm deliveries (≤ 37 weeks) to 9.40% or less. o Low birth weight (LBW) (1,501 grams to < 2,500 grams) babies to

7.80% or less. o Very low birth weight (VLBW) (< 1,500 grams) babies to 1.40% or

less.

• To increase Healthy Kentuckians (HK) results.

Measurements: Overall effectiveness of the Program is measured through performance against program goals, annual participation rates, Healthy People 2020, audited HEDIS®2 results, HK, and compliance with Passport’s Perinatal Care Clinical Practice Guidelines.


Annual Participation Rate Eligible members are identified and passively enrolled in the Program. Members that return pregnancy risk questionnaires are considered enrolled. Members may “opt-out” of the Program and elect not to receive services by notifying any of the Program staff or the Care Connector Program, either telephonically or in writing. Participation Rates are tracked and reported annually.

Graph 1. 2019 Birth Outcomes: Healthy People 2020: Goals for LBW, VLBW, and Preterm Deliveries are based on Passport’s Corporate 2019 Goals and Healthy People 20203

Graph 2.

3 http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26

61 44 39

115 98 108145

107 11583

3345

96

282

141

203

130

625

256

159 152

82

265

49

1 1 03 2 1 2 1

31

6

1

January February March April May June July August September October November December

Members Engaged Members Identified Declined Participation

40.70% Participation

0.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%8.00%9.00%

10.00%

LBW (1,501 GRAMS TO < 2,500 GRAMS)

VLBW (< 1,500 GRAMS) PRETERM DELIVERIES (≤ 37 WEEKS)

7.80%

1.40%

9.40%

7.80%

1.40%

9.40%

Healthy People 2020 vs. Passport Goals

Healthy People 2020 Goal 2019 Passport Goal

http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

2016 2017 2018 2019

5.56%

6.99%

7.81%

9.25%

LBW (1,501 grams to < 2,500 grams)

Goal 7.8%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

2016 2017 2018 2019

1.50%

1.28%

1.98%2.01%

VLBW (< 1,500 grams)

Goal 1.4%

4 5

Graph 3.

Graph 4. 6

4 This data is a representative sample, not the whole data set. A significant number (2,664) of claims were excluded due to missing information. 5 This data is a representative sample, not the whole data set. A significant number (2,375) of claims were excluded due to missing information. 6 This data is a representative sample, not the whole data set. A significant number (2,664) of claims were excluded due to missing information.

6

4 5

7


10.20%

10.40%

10.60%

10.80%

11.00%

11.20%

11.40%

11.60%

11.80%

12.00%

2016 2017 2018 2019

10.78%

11.60% 11.64%

11.87%

Preterm Deliveries (≤ 37 weeks)

Goal 11.4%

7

Graph 5.

Maternity HEDIS® Results

The 2019 HEDIS® Results are based on measurement year 2018 data.

The Mommy Steps Program uses the following HEDIS® measures to assess Prenatal and Postpartum Care: 1. Prenatal and Postpartum Care (PPC)

The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care. • Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care

visit as a member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization.

• Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

7 This data is a representative sample, not the whole data set. A significant number (2,375) of claims were excluded due to missing information.

6 7


Findings: In a sample of 407 women with live birth deliveries, 277 (77.89%) had a timely prenatal care visit and 213 (63.39%) had a postpartum care visit within the 21 to 56 day time frame.

Graph 6. Graph 7.

The goals to meet or exceed the 2019 Quality Compass® 90th Percentile for Timeliness for Prenatal Care (90.98%) and Postpartum Care (74.36%) were not met. For measurement year 2018, Timeliness for Prenatal Care met the 2019 Quality Compass® 10th Percentile and Postpartum Care met the 2019 Quality Compass® 33.33rd Percentile.

Healthy Kentuckians (HK) Results

The 2019 HK Results are based on measurement year 2018 data.

1. Prenatal Risk Assessment Counseling and Education The percentage of pregnant members who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement year, whose medical record contains the following: • Documented Tobacco Use – evidence of screening for tobacco use during one of their first

two prenatal care visits or during one of their first two prenatal care visits following enrollment

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

MY 2015 MY 2016 MY 2017 MY 2018

86.83%81.00%

71.28%77.89%

Prenatal CareGoal 90.98%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

MY 2015 MY 2016 MY 2017 MY 2018

66.29% 64.93%

55.59%

63.39%

Postpartum Care

Goal 74.36%


• Documented Alcohol Use – evidence of screening for alcohol use during one of their first


• Documented Substance/Drug Use – evidence of screening for substance/drug use during

one of their first two prenatal care visits or during one of their first two prenatal care visits following enrollment

• Assessment of and/or Education/Counseling for Nutrition – evidence of assessment of

and/or education/counseling for nutrition during one of their first two prenatal care visits or during one of their first two prenatal care visits following enrollment

• Assessment of and/or Education/Counseling for OTC/Prescription Medication – evidence of

assessment of and/or education/counseling for OTC/prescription medication during one of their first two prenatal care visits or during one of their first two prenatal care visits following enrollment

• Screening for Domestic Violence – evidence of screening for domestic violence during one

of their first two prenatal care visits or during one of their first two prenatal care visits following enrollment

• Screening for Depression – evidence of screening for depression during one of their first


• Screening for Depression During a Postpartum Visit – evidence of screening for depression

during a postpartum visit

Findings: In measurement year 2018, a total of 7,248 members were identified. In a sample of 317 women, 256 (80.76%) had counseling and education for tobacco use, 242 (76.34%) had counseling and education for alcohol use, 241 (76.03%) had counseling and education for drug use, 152 (47.95%) had counseling and education for nutrition, 160 (50.47%) had counseling and education for OTC/prescription medication, 164 (51.74%) were screened for domestic violence, and 126 (39.75%) were screened for depression. There were 188 (59.31%) women screened for depression during a postpartum visit where the sample size was 258 instead of 317.


Graph 8. Graph 9.

Graph 10. Graph 11.

Graph 12. Graph 13.

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

MY 2015 MY 2016 MY 2017 MY 2018

75.39%

84.81%

78.26%80.76%

Tobacco Use

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

MY 2015 MY 2016 MY 2017 MY 2018

72.51%81.77%

90.06%

76.34%

Alcohol Use

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

MY 2015 MY 2016 MY 2017 MY 2018

70.95%

82.04%89.44%

76.03%

Drug Use

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%

MY 2015 MY 2016 MY 2017 MY 2018

39.69%44.75%

38.51%

47.95%

Nutrition

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

MY 2015 MY 2016 MY 2017 MY 2018

88.47%

27.62%

44.10%50.47%

OTC/Prescription Medication

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

MY 2015 MY 2016 MY 2017 MY 2018

25.28%

42.27%37.27%

51.74%

Domestic Violence


Graph 14. Graph 15. • Specific results include:

o Counseling and education for Tobacco Use increased by 2.50 percentage points

o Counseling and education for Alcohol Use significantly decreased by 13.72 percentage points

o Counseling and education for Drug Use significantly decreased by 13.41 percentage

points o Counseling and education for Nutrition increased by 9.44 percentage points o Counseling and education on OTC/Prescription Medication increased by 6.37

percentage points o Counseling and education for Domestic Violence significantly increased by 14.47

percentage points o Counseling and education for Depression decreased by 4.35 percentage points o Counseling and education for Postpartum Depression increased by 7.65 percentage

points

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

MY 2015 MY 2016 MY 2017 MY 2018

39.47%

82.32%

44.10%39.75%

Depression

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

MY 2015 MY 2016 MY 2017 MY 2018

60.52%

82.86%

65.22%72.87%

Postpartum Depression


Analysis

HEDIS®: Results for HEDIS® 2019 (MY2018) indicated Timeliness for Prenatal Care had an increase of 6.61 percentage points and Postpartum Care had an increase of 7.80 percentage points. Timeliness for Prenatal Care measure achieved the 2019 Quality Compass® 10th Percentile and Postpartum Care achieved the 2019 Quality Compass® 33.33rd Percentile. Healthy People 2020: LBW, VLBW, and Preterm Deliveries are below the Healthy People 2020 goals. According to the most recent statistics, Passport’s LBW rates are below state and national rates.8 For LBW there was an increase of 1.18 percentage points, VLBW remains relatively the same with a slight increase of 0.04 percentage points and Preterm Deliveries ≤ 37 weeks remains relatively the same with a slight decrease of 0.17 percentage points in 2019. Community and Provider Engagement: Community activity involvement included collaboration with March of Dimes, Health Service Advisory Committee, Kentucky Moms Program, Plan of Safe Care Neonatal Abstinence Syndrome (NAS) Coalition, Head Start and Early Head Start Programs, and the Crib Program in association with Lincoln Trail’s Health Access Nurturing Development Services (HANDS), among others. Member Incentive Program: Passport utilized our Member Incentive Program targeted toward increasing provider and member awareness of the importance of prenatal and postpartum care. Members who attended six (6) prenatal visits and returned their incentive form received $50. Members who attended their postpartum check-up within three (3) to eight (8) weeks after delivery and returned their incentive form received $50. Members who had a C-Section and had their incision checked within seven (7) to fourteen (14) days after delivery and returned their incentive form received $10. For 2019, a total of 675 members took advantage of these rewards. There were 339 prenatal, 245 postpartum screenings, and 91 C-Section incisions checked. By utilizing member incentives, we increased members’ compliance with postpartum examinations, as well as increasing initiation of timely prenatal care. Risk Stratification: In 2019, Passport had an average of 8,792 (6,3599) members per quarter enrolled in the Mommy Steps Program. There was an average of 2,012 (1,0539) members per quarter identified as high risk. There was an average of 180 (2559) high risk members actively engaged with a Maternity Care Advisor. These members received one-on-one telephonic contact and educational materials specific to their high-risk condition. Member Complaints: During 2019, there were no complaints received regarding the Mommy Steps Program or any Maternity Care Advisors.

8 National Center for Health Statistics. “March of Dimes – Peristats,” www.marchofdimes.com/peristats. 2015. 9 These numbers denote 2018 data.

http://www.marchofdimes.com/peristats


Maternity Members by Age Group

Graph 16. Passport evaluates the ages of members who enroll in the Program to ensure appropriate materials and resources are allocated to assist members with their pregnancy. Findings: Graph 16 represents the different age ranges for members who delivered. Education and information are distributed via the Member and Provider Handbooks, Member Newsletter, New Member Packets, and Member Program brochures. Education is provided through internal department meetings and internal referrals between the Program and Behavioral Health (BH) is encouraged.

Ages 10 - 147

Ages 15 - 19594

Ages 20 - 345,092

Ages 35 and Older529


Total Deliveries by Type

Graph 17. Passport evaluates the delivery types of members who are enrolled in the Program to assist in reduced preterm, LBW and VLBW deliveries. Findings: Graph 17 represents the total number of delivery types.

4,128

2,105

740588

128

# of Vaginal Deliveries # of Cesarean Deliveries # of Preterm Deliveries # of LBW Deliveries # of VLBW Deliveries


Emergency Department and Inpatient Utilization

Graph 18. Graph 19.

Graph 20.

Passport identifies the utilization of Emergency Department (ED), Inpatient Admission, and 30-day Readmissions. Findings: Graphs 18, 19, and 20 represents a sample of members who were pregnancy or delivered and is a comparison of ED/inpatient utilization six months prior to and six months following engagement. After program involvement during 2019, the data indicates: • A decrease in the numbers of members accessing the ED (-66.40%), an increase in inpatient

stays (+215.85%) and no change in readmissions (0%). • A decrease in the number of visits to the ED (-62.97%), an increase in inpatient stays

(+214.77%) and no change in readmissions (0%). We expect an increase for this population due to deliveries and related costs.

424

157

250

84

25%8%

Prior Post

ED Utilizationn = 993

ED Visits # Members Percentage of Total Members

88

277

82

259

8%

26%

Prior Post

Inpatient Utilizationn = 993

IP Visits # Members Percentage of Total Members

5 5 5 5

1% 1%

Prior Post

Readmissions within 30 Daysn = 993

Readmission Visits # Members Percentage of Total Members


Maternity Cost Trends

Graph 21. Passport looks to monitor costs related to ED utilization, Inpatient Admission, and 30-day Readmissions. Findings: Graphs 21 represents a sample of members who were pregnant or delivered analyzing utilization six months prior to six months following engagement. After program involvement during 2019, the data demonstrates: • A decrease of $94,924.76 in ED costs. • An increase of $873,406.20 in inpatient costs. • A decrease of $4,903.71 in readmission costs. We expect an increase for this population due to deliveries and related costs.


Overall Financial Impact for Identified Sample of Maternity Members

Graph 22. Summary: Graphs 22 represents the overall impact for the identified sample of members who were pregnant or delivered in the Program analyzing utilization six months prior to and six months following engagement. After program involvement during 2019, the data demonstrates a potential cost increase of $773,577.73. This is not representative of the entire program, but instead only the sample for analysis. This represents what is a potentially significant higher amount for the entire program population. We expect an increase for this population due to deliveries and related costs. Members are educated on signs and symptoms that indicate that need to seek care at appropriate levels, which includes possible ED visits, as well as inpatient utilization.

Total Cost Post CM$1,330,441.67

Total Cost Prior to CM$556,863.94

n = 993


Graph 23. Passport aims to achieve or exceed a score of 90% or above in all areas of member satisfaction. Findings: Graph 23 represents the members’ satisfaction regarding services received. The areas surveyed include: 1) Understand Health Condition 2) Professional and Courteous Manner 3) Help Received from Staff 4) Help with Making Decisions 5) Value of Written Materials The goal is to achieve 90% satisfaction for each area. During 2019, 739 surveys were mailed to members, of which 15 members responded (2% return rate). Of the members who responded to the survey, 100% reported they could understand their health condition better, 100% reported the Maternity Care Advisor had a professional and courteous manner, 100% reported they received help from the Maternity Care Advisor when requested, 87% reported they received help with making decisions regarding their health, and 100% reported the written materials they received had value. Only one topic (Help with Making Decisions) fell below satisfaction rate target. Target exceeded in all other areas.

100% 100% 100%

87%

100%97%

50%

60%

70%

80%

90%

100%

UnderstandHealth Condition

Professional andCourteous Manner

Help Received fromStaff

Help withMaking Decisions

Value ofWritten Materials

Total

Member Satisfaction Results for Services Received

Goal 90%

n = 15


Barriers and Opportunities

Barrier: Initiation of prenatal care continues to be a difficult measure to increase as members must first have a positive pregnancy test with an estimated date of confinement (EDC) to apply for Medicaid benefits. Meanwhile, Passport is not able to outreach to non-members due to contractual and/or regulatory restrictions.

Opportunity: • Increase member identification and engage in OB care by:

o Data mining to identify all plan eligible pregnant members to be added to the program and subsequent mailing outreach.

o Regular review of the new member Health Risk Assessment (HRA) to identify pregnant members new to Passport, and outreach to encourage early and regular OB care.

o Performing daily review of the 24-Hour Nurse Advice Line Report and conduct telephonic outreach to members that think they might be pregnant or have a pregnancy question.

o Implementing a specialized maternity stratification to increase early identification to intervene and achieve positive birth outcomes.

• Community Outreach: o Collaboration with community partners, such as Healthy Start, HANDS, and local

Departments of Health to increase awareness of the Program. o Provide education and assistance with pregnancy questions/issues via the 24-Hour Nurse

Advice Line. o Distribute educational materials at health fairs and community baby shower events.

Barrier: Lack of member awareness of the importance of regular prenatal care, and the importance and availability of the Program and services. Opportunity: Member Outreach: • Make every member contact count to educate members on:

o The importance of early and regular prenatal care to identify complications early so they can be addressed by the OB provider.

o The warning signs during pregnancy and when to call the OB provider. o Stress habits that support a good outcome for mother and baby. o Identify habits that cause harm to the mother and baby and attempt and provide support and

resources for intervention. o The availability and convenience of the 24-Hour Nurse Advise Line and Audio Health Library. o Available resources to assist with keeping appointments (e.g., transportation).

• Continue member engagement rewards to encourage early and regular prenatal care as well as

timely postpartum care.

• Improve identification and coordination of BH issues, and other social determinants of health to improve care management protocols.


Barrier: Difficulty in identifying modifiable risk factors that could result in a poor birth outcome for the member. Opportunity: Provider Outreach: • Collaborate with OB providers to notify the Program of members with modifiable risk factors.

• Collaborate with Provider Relations to educate OB providers during all site visits to promote a

relationship with both the OB providers and office managers. • Provide all OB provider offices with our Program brochure. • Request the ACOG or “ACOG like” form utilized by OB providers be sent to the program for each

member after the first prenatal visit. • Continue to educate OB providers on the importance of notifying the Program when a member

becomes high risk. • Active participation in provider organizations, such as the Louisville Obstetrical and

Gynecological Society, the Kentucky Section ACOG, the Kentucky Perinatal Society, and others.

Barrier: Difficulty in identifying high risk members for the Program. Opportunity: • Implemented a maternity risk stratification report at the end of 2019.

• Work continues to identify any issues with the maternity risk stratification to enhance and target

high risk members.


Interventions completed in 2019: • The program interacted with 2,440 members in 2019. • Implemented policy to permit separate reimbursement for devices and insertion for postpartum

insertion of long acting reversible contraceptives (LARC’s) which should result in decreased short-interval pregnancies for some of our highest risk members.

• Collaborated with CareMessage vendor to provide information on preventative messages to members with Passport sponsored cell phones.

• Held regular meetings of the Women’s Health Committee to review, discuss, and create criteria,

policies and interventions to improve the health and well-being of pregnant members and birth outcomes.

• The Crib Program provided Pak-N-Play cribs to Passport members in need within their coverage

area. The Lincoln Trail Health District is partnered with Passport to split the costs. This program promoted “Safe Sleep” and educated members on the ABCs of Safe Sleep to lessen the number of infant deaths that occur due to co-sleeping or other unsafe sleep habits.

• Participated in community coalitions such as the March of Dimes, Head Start and Early Head Start programs, and others.

• Participated in community baby showers to provide member education on pregnancy, delivery,

and postpartum topics to improve birth outcomes. • Performance Improvement Project (PIP) Smoking Cessation: The goal is to reduce preterm

births, LBW, and VLBW babies via the implementation of OB provider education to increase screening and education for pregnant/postpartum members about tobacco use and second-hand smoke exposure. There is an added goal to increase referrals to KY Quit Line for additional member smoking cessation adherence.

• Preterm Birth Prevention Initiative: The goal is to improve birth outcomes by continuing to educate

providers and support best practices related to clinical evidence for the use of progesterone therapy and universal cervical length screening to reduce preterm delivery.

• Administered the Patient Health Questionnaire (PHQ) 2 to members in the Program. There were 1,935 members screened, and less than 1% of those members had a positive result. Further depression screenings were conducted using the Edinburgh Postnatal Depression Scale (EPDS) Assessment with those members. There were eight (8) members referred for BH services. Data collection issues with the previous medical management platform are likely impacting the data. We hope that our move to the Identifi platform will resolve this for 2020.


Prenatal member outreach: • Educated members regarding the importance of early and regular prenatal care through:

o Telephonic outreach o Individualized educational materials to members that were spoken with o Member newsletters o On-hold SoundCare messages o Passport’s website o CareMessage

• Distributed new member packets to newly identified pregnant members. • Distributed March of Dimes “My pregnancy month by month” booklet to pregnant members.

English and Spanish versions were mailed as appropriate.

Postpartum member outreach: • Distributed postpartum reminder postcards and performed telephonic outreach calls to

postpartum members.

• Community initiatives related to the identification of members and promotion of healthy pregnancies by participation in: o fundraising and walking in the local March of Dimes. o Head Start and Early Head Start, HANDS and Kentucky Moms Programs. o Plan of Safe Care NAS Coalition.

• Continued to improve integration and collaboration to improve overall coordination of care for

members with co-existing medical and BH diagnoses/conditions via bi-monthly meetings and case discussions.

• Distributed the Member Satisfaction Survey to members engaged in the Program, reviewed surveys as received and conducted outreach to those members who indicated “fair” or “poor” responses on their survey (if the member completes contact information section of the survey tool) and monitored surveys for trends. Provided feedback to individual staff when appropriate and addressed any identified areas that needed improvement, none identified.

Planned Interventions for 2020: • Continue with the policy to permit separate reimbursement for devices and insertion for

postpartum insertion of LARC’s which should result in decreased short-interval pregnancies for some of our highest risk members.

• Continue collaboration with CareMessage vendor to provide information on preventative messages to members with Passport sponsored cell phones.


• Passport Goals for LBW, VLBW and Preterm Births: Goals for 2020 will continue to align with the Healthy People 2020 Goals: o LBW – 7.80% o VLBW – 1.40% o Preterm – 9.40%

• Preterm Birth Prevention Initiative: The goal is to improve birth outcomes by continuing to educate providers and support best practices related to clinical evidence for the use of progesterone therapy and universal cervical length screening to reduce preterm delivery.

• Substance Abuse Referral & Treatment: The goal is to reduce preterm births, LBW, and VLBW babies resulting from substance abuse via the implementation of processes to ensure that the counseling and treatment for pregnant women contain no gaps in care from detox to inpatient/residential care and throughout outpatient services to increase recovery rates. o Work to develop a partner relationship for care management of pregnant and postpartum

members with diagnosis of substance use/abuse disorder. • Reducing Postpartum Readmissions: The goal is to improve postpartum care and reduce

readmissions for our members post-delivery. Maternity Care Advisors place 2-4 Day postpartum discharge calls to all members who had a C-section and to any member having a vaginal delivery at risk for readmission. During the calls the nurses will review the member’s health status and provided guidance to the member when needed to seek care from their OB provider.

• Continue to encourage provider participation at The Women’s Health Committee. Comprised of

OB providers and internal staff and meets quarterly to collaboratively review, discuss, and create criteria, policies and interventions to improve the health and well-being of pregnant members and birth outcomes.

• OB provider interventions include:

o Educate OB providers on Passport’s Perinatal Care Clinical Practice Guidelines to increase compliance and postpartum visits.

o Increase adherence and documentation of postpartum visits between 21-56 days post-delivery.

o Decrease postpartum readmissions occurring between 1-14 and 15-30 days post-delivery. • Member Incentive Program rewards to members who have an incision check following a

Cesarean delivery and for attending a postpartum visit between 21 and 56 days.

• Continue member outreach by: o Distributing weekly member welcome packets to newly identified pregnant members. o Distributing the March of Dimes “My pregnancy month by month” booklet to those members

who call in and request a copy. o Newly created maternity booklet that we will be looking to distribute to members in 2020.

• Implement recommendations from the IPRO focus study on NAS. The team has reviewed the

recommendations and will create a plan for which recommendations to implement in 2020.


• Member interventions include: o Education about the warning signs of postpartum complications. o Education on the importance of postpartum visits. o Education on adherence of a postpartum visits 21-56 days after-delivery. o Education on adherence of a C-section incision check 7-14 days after cesarean delivery.

Improving Home Health Provider Network: • Work on identifying Home Health partner for postpartum home visits for high risk members. Postpartum member outreach: • Educate members regarding the importance of postpartum follow-up through:

o Telephonic outreach o Member newsletters o On-hold SoundCare messages o Passport’s website o CareMessage o Member educational materials o Mailing weekly postpartum reminder postcards to newly delivered members o Perform telephonic outreach to all postpartum members without delivery information on file o Screen all postpartum members spoken with for depression using the PHQ-2 and EPDS

Assessment and refer to the BH team as indicated. Prenatal member outreach: • Continue prenatal member outreach by educating members regarding the importance of early

and regular prenatal care through: o Telephonic outreach o Member newsletters o On-hold SoundCare messages o Passport’s website o Care Messaging o Member educational materials

• Member Incentive Program rewards to members who attend six (6) prenatal visits. • Evaluate the Program interventions to establish which are the most productive and re-organize

resources, as needed. • Maintain member engagement/incentive rewards to encourage early and regular prenatal care

with an OB provider. • Increase community outreach initiatives related to the identification of members and promotion of

healthy pregnancies by: o Continue fundraising and walking in the local March of Dimes. o Continue additional opportunities to engage members in early and regular prenatal care. o Continue collaboration with providers to improve birth outcome and infant mortality.


• Review Member Satisfaction Surveys as received and conduct outreach to those members who indicate “fair” or “poor” responses on their survey (if the member completes contact information section of the survey tool).

• Monitor for trends, provide feedback to individual staff and address any identified areas that

needed improvement. • Improve integration and collaboration to enhance overall coordination of care and case

management for members with co-existing medical and BH diagnoses/conditions with the support of a social worker to the Mommy Steps Team.

Overall the Program noted improvements in 2019. Based upon the 2019 evaluation, Passport will continue to strive towards the overall goal to improve the health, quality of life and birth outcomes for our pregnant members.

2019 Mommy Steps Program Evaluation...The Mommy Steps Program (Program) is designed to improve...

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Transcript of 2019 Mommy Steps Program Evaluation...The Mommy Steps Program (Program) is designed to improve...