Falling through the Cracks:

1. Falling through the Cracks: An Analysis of Care Coordination for Low Income Pregnant Women in Hennepin and Ramsey Counties A Presentation to the Maternal and Child Health Institute: Addressing Health Disparities June 27, 2002 Cheryl Fogarty, Minnesota Department of Health

2. Perinatal Survey Group Megan Ellingson, Health Program Analyst, MDHFS Cheryl Fogarty, Infant Mortality Consultant, MDH Marilyn Kennedy, Research Scientist, MDH Gretchen Musicant, Dir. Of Community Initiatives, MDHFS Fritz Ohnsorg, Research Scientist, formerly of MDH and MDHFS Mary Rossi, Perinatal and Women’s Health Consultant, formerly of MDH Alexandra Stillman, Project LID Intern, formerly of MDHFS

3. History/Background • Two local infant mortality review projects--known as Project LID--declared “system fragmentation” a contributing factor to infant mortality. • Wide variation in understanding of what “Care Coordination” and “Case Management” implied in terms of actual practice.

4. Project Goal To establish a baseline description of perinatal care coordination services and capacity in Hennepin and Ramsey Counties in order to provide a springboard for discussions about filling service gaps.

5. Research Design • Iterative Qualitative Research (“Structured Discussions”) • Qualitative Surveys/Guided Conversations • Community clinics, public health nursing, health plans • Hospitals • Data Analysis • Feedback on and discussions about drafts of the survey findings with survey respondents, the Council of Health Plans, and DHS

6. Survey Components • Mission, Philosophy and Scope of Practice • Community and System Level Activities • Client Level Activities • Financial and Capacity Issues • Also asked for recommendations from each respondent

7. Findings • Health care and social service systems are fragmented by institutional, bureaucratic and reimbursement barriers. • Communication between health care and social service systems is poor. • Populations of color, American Indians, refugees and immigrants most impacted.

8. Findings (cont.) • A large number of pregnant women at-risk of poor birth outcomes are not being offered coordinated care by a public health nurse. • 1,000 low income women seen by PHN, prenatally • 8,000-9,000 low income pregnancies annually • The current system lacks accountability. • No outcomes from PHNs, health plans, or DHS

9. Findings (cont.) • Low income women are not assured continuous health insurance throughout their childbearing years. • No way to ensure access to primary health care, dental care, care for chronic conditions, family planning, preconception care, early pregnancy identification, and early and continuous prenatal care.

10. “We must recognize that, in some large measure, problems with infant ill health are a legacy of women’s ill health generally.” --Dr. Paul Wise

11. Limitations • Sampling adequacy: • No private providers • No consumers • Limited to Hennepin and Ramsey Counties. Not applicable beyond those counties

12. Limitations (cont.) • Organizational complexity • Variability among health plans • Difficulty describing their operations in a survey based on a public health model • Selective reimbursement • Community health centers & PHN agencies reimbursed • Potential researcher bias

13. Discussion Highlights Community Update since 1999: • Twin Cities Healthy Start • TANF/Family Home Visiting • MN Pregnancy Assessment Form • Risk assessment tool, used for reimbursement • Identifies medical, social, and behavioral risk factors • Does not prompt or facilitate interventions and referrals. • Data needed for accountability

14. Discussion Highlights cont. • PHN, other effective care coordination models • PHN model, home visiting, supported in literature • Doulas • Nurse midwives • Telephonic case management (?)

15. Community Perspectives • Lack of health care and insurance • Alcohol and other substance abuse • Lack of information and education • Discrimination by health care providers Twin Cities Healthy Start, American Indian Perspectives on Pregnancy and InfantCare, American Indian Policy Center, September, 2000.

16. Community Perspectives, cont. • “respondents who were in relationships with community-based providers were more likely to follow-through in arranging timely prenatal care.” • “Medical home” supported in research literature. (Gazmararian et al, 1999) Twin Cities Healthy Start, African American Prenatal CareSurvey, Rainbow Research, November, 2001.

17. Recommendations • Work Group to develop a perinatal care system that provides care coordination services shown to be effective for socially at-risk pregnant women. • Adequate and stable resources to rebuild system capacities of public health and community-based providers of comprehensive perinatal care coordination services.

18. Recommendations (cont.) • Provide support to “service networks” developed by Twin Cities Healthy Start. • Provide continuous health insurance to all women of child bearing age.

19. Contact Information Cheryl Fogarty MN Dept. of Health 651-281-9947 Megan Ellingson Mpls. Dept. of Health and Family Support 612-673-3817