Maternal Health Services

State: FL Type: Model Practice Year: 2005

Brevard County is a geographically and economically diverse community with a population of 500,000 citizens, ranging from urban/high-tech to sparsely populated rural areas. There are approximately 255,000 women residing in Brevard and, of that number, approximately 36% (or, 91,800) are of child bearing age, and of those, 12% below the federal poverty level. Healthy People 2010 objectives for women and infants are indicative of a community’s overall health and ability to respond to the priority needs of its citizens. The health department has a long-standing history of providing maternity care to indigent and low-income pregnant women, however, issues related to access to quality care, lack of continuity of care, and litigation issues between CHD clients and private physicians, led the health department to seek a network of cooperative agreements, services, and funding that now serves as a model practice in Florida. The goal was to provide high quality, comprehensive maternity services to all of Brevard’s pregnant women. Objectives included: 1) identifying and removing barriers to prenatal care; 2) providing comprehensive, high quality ante partum care; 3) improving high risk maternity care; 4) ensuring continuity of care; 5) reducing litigation issues between health department clients and private providers; and 6) improving maternal/infant outcomes. There are no other counties in Florida that this type of extensive network of partnership agreements to ensure that all women receive quality maternity care. This program has successfully met, and continues to meet, the needs of all pregnant women in Brevard, surpassing Healthy People 2010 goals and setting public health standards. Overall, this is a win-win collaborative venture that can be replicated within any community that seeks to maximize resources and improve outcomes for women and children.
Brevard’s expanding service industry and self-employment segments have resulted in jobs that pay less and offer little, or no, health insurance coverage for women and families. The highest rates of uninsured in Brevard County are among the unemployed (38.2%) and households with incomes less than $35,000. Over 36% of Brevard’s employed actually earn less than 100% of the Federal Poverty Level (FPL), and are uninsured. Approximately 255,000 women residing in Brevard and 36% are of child bearing ages (15 to 44), with the most prolific reproductive years being between 25 and 34. Estimates of female fertility in Brevard surpass the rate in Florida or nationwide, while the ratio of child-bearing women per physician is higher than the state average. In past years, the health department experienced declining rates of client satisfaction, below average patient compliance with prenatal and follow-up care, and disjointed maternity care processes with private entities. Further, between public and private sectors, antagonistic professional relationships existed and issues of litigation, arising from deliveries performed by private physicians for health department clients. These combined factors demonstrated the need for reassessment and restructuring of indigent maternity services and post-partum follow-up care in Brevard County. Considering that as many as 46% of the hospital deliveries qualified for Medicaid, it was apparent that a collaborative approach would better meet the needs of this vulnerable population by strengthening relationships between public and private sectors and making best use of community resources. As a result, today in Brevard County, pregnant women receive superior care that makes best use of resources, removes financial barriers, reduces risks associated with preterm delivery, increases optimal pregnancy outcomes, and addresses issues of liability. The maternity program has successfully met, and continues to meet, the needs of all pregnant women in Brevard, surpassing Healthy People 2010 goals and setting public health standards. Creative strategies and use of existing resources have served to meet the needs of clients and the issues of private providers. Private physicians are hired under special contract as health department staff and reimbursed at a rate less than Medicaid Direct Service Fee, with coverage under Sovereign Immunity by the State of Florida, thereby reducing liability risk and costs. Delivery physicians meet with health department clients at the health department on a monthly basis. Hospitals provide delivery and lab services throughout the pregnancy and assume the responsibility for reimbursement. Together, this program’s services surpass those provided by public or private providers alone. Due to the success of this program, Brevard County, as the ninth largest county in Florida, now has the distinction of having the fourth largest maternity program. Uninsured or underinsured women no longer face financial barriers to comprehensive services and quality care. Furthermore, no woman is denied high-risk maternity care, and, all women have an opportunity to build a relationship with the delivery physician. There are no other counties in Florida that incorporate this type of partnership arrangements between public and private agencies, hospitals, and practitioners to ensure that all women have access to prenatal care, delivery care, and post-partum follow-up care.
Agency Community RolesThis program demonstrates the power of community partnerships. This network was established over a period of a few months but continues to evolve, and now, provides all of Brevard’s women a comprehensive range of services that no private or public entity could provide alone. The health department offers professional medical and nursing staff, nurse case managers, licensed dieticians, lactation consultants, social workers, as well as administrative support and facilities within the existing family planning program at three clinic sites that cover the north, central, and south regions of Brevard. The health department also provides a mechanism for uninsured or underinsured clients to pay a low-cost, cash alternative that includes prenatal care and doctor fees by establishing repayment plans, however, these costs are most often absorbed by the heath department and are considered an in-kind contribution. They have further committed to the success of this program by the outright purchase of equipment and full-time staffing of ultrasonography all three sites. This contribution includes a board-certified obstetrician with expertise in ultrasonography and a trained technician. In addition, Healthy Start Coalition of Brevard contributes monetarily to clinical services, prenatal screening, counseling and education, and nurse case management of substance exposed newborns and substance abusing mothers. All five local hospitals will receive health department clients for deliveries and assume reimbursement responsibilities (either by qualifying client for emergency Medicaid, repayment plan, or absorbing costs) for health department clients. Over a dozen physicians have contracted as part-time employees with the health department to perform a monthly prenatal visit with each client at the health department and perform the deliveries at local hospitals. High-risk clients are seen by perinatologists from Orange County’s prestigious Arnold Palmer Hospital (Orlando Regional Healthcare). These specialty physicians provide expert care and high-risk outpatient services at a local hospital (Wuesthoff Memorial Hospital). High-risk services include: frequent assessment, amniocentesis, ultrasounds, genetic counseling, and continuous professional counseling and support. A health department dedicates a nurse specialist to the high-risk clinic to ensure documentation integrity and continuity of care. Senior residents from Arnold Palmer Hospital provide routine maternity care at health department sites under the joint supervision of health department and Arnold Palmer medical staff. This particular partnership has been well received by clients and is at the heart of an ever increasing rate of patient satisfaction and increase in numbers of women seeking care at the health department. To complete this package of services, post-partum examinations and follow-up family planning is provided at the health department. If the client prefers, at least one physician per region has agreed to perform post-natal tubal ligations. The health department, in turn, provides pre- and post-procedure counseling, as well as, in-house vasectomy for men.  Costs and ExpendituresAlthough the value of this program can not be totally accessed in terms of dollar figures, the public and private partners have experienced fiscal advantages related to this program through efficient use of resources and reduced litigation. Because it provides equitable solutions for all parties, it has been wholeheartedly embraced by all stakeholders. Reduction of costs to taxpayers due to reduction in preterm deliveries and increase in positive pregnancy outcomes are also realized. Cost savings can also be calculated as increased numbers of indigent and low-income clients and high-risk clients receive comprehensive prenatal, ante partum, and post-natal care. Partnership contributions include direct funding, staff, equipment, and facilities result in decreased cost of delivery of care, decrease cost of diagnostics, labs, procedures and other interventions through better working relationships between public and private sectors. Client services are addressed through a combination of fiscal measures such as: indigent care contributions, Medicaid, private insurance, or “global” cash payment services in which repayment plans are established, but, frequently absorbed by the heath department as an in-kind contribution. Even so, fiscal success for the all partners and reduced litigation has been realized for the private sector, and, as reduced cost per service resulted, more Brevard clients are served. Sustainability is realized because this program equitably meets the needs of all stakeholders. Consequently, as it has grown in scope and complexity, it has attained even greater success and acceptance each year by functioning as an interdependent community-based response to an essential public health need, and thus, perpetuating continuous buy-in by all stakeholders as it serves to provide the “safety net” of care originally envisioned. Furthermore, this practice has proven a financial success within the health department through funding and reimbursement sources, as well as, for its private partners through reduced litigation and risk management. Overall, the program has sustainability and has proven to be a win-win venture that can be replicated within any community that seeks to reach and improve outcomes for this vulnerable target population.  ImplementationThe Brevard County Health Department met with local obstetricians, hospital representatives, and agencies to assess and restructure delivery system processes. Together they devised a plan to improve access and remove financial barriers for all of Brevard’s pregnant women. Private physicians, area hospitals, maternal-infant welfare agencies, and the health department created an interdependent network of services that provides a “safety net” of maternity care, experiences greater success with each ensuring year, and serves as a model of community collaboration. Once meetings were held to ascertain each community leader or agency’s role, restructuring of system processes and implementation of the plan began immediately. Indigent and low-income pregnant women (0-185% FPL) receive a full range of maternity services through partner contributions for indigent services or Medicaid. Underinsured clients may access care via private insurance or a health department-based, low-cost program that includes full prenatal care and delivery obstetrician fee as a monthly repayment plan. Fully insured clients may also seek care at the health department if they wish to take advantage of some of the unique programs and counseling services offered. Private physicians often refer their clients for selected services such as prenatal counseling, nutritional counseling, or high-risk maternity services. Since these maternity services are incorporated within the existing family planning program, the majority of employees are cross-trained within the family planning program to serve this population. Maternity clients receive screening, prenatal and nutritional counseling, education, social services, examinations, sonograms, lab services, and are referred early in their pregnancy to the private physician who will deliver their baby. Services begin from the moment a client tests positive for pregnancy, or are referred to the health department for maternity services. Upon their initial visit, each client is scheduled for prenatal counseling and is assigned to a private sector delivering physician. This doctor sees each client at the health department at least once a month prior to delivery and provides delivery services at one of five area hospitals. Clients receive a full range of maternity services as a result of the combined resource capacity of the private and public sectors. This includes: pregnancy education and counseling, pregnancy care and monitoring, ultrasonography, high risk maternity services by perinatologists, high risk interventions, in-house sonography services, nutritional counseling, social services, and referrals through local partnerships. Implementation of this program has strengthened the provision of ante partum care for all women in Brevard County.
Limitations related to replication are based on the extent to which the health department and private providers can combine resources and reach agreements to deliver comprehensive, high-quality care to all women in their community regardless of income. There may be existing coalitions or committees that can serve as a starting point for developing relationships and partnerships such as, professional organizations, MAPP processes, regional health councils, etc. There are always challenges to reaching consensus on how to deliver multi-disciplinary, multi-agency services. The impetus for Brevard was the increased litigation issues arising between health department clients and private physicians. Responding to these concerns in a good-faith manner allowed the health department to broaden the scope to meet the needs of all pregnant women in Brevard. Thus, taking advantage of any opportunity that brings physicians, hospitals, health agencies, and others to the table can result in overall system changes. This program meets the criteria for local public health system performance standards by assessing and improving the quality and effectiveness of population-based preventative services. As a result, pregnant women and families receive superior screening, prenatal examinations, treatment, interventions, referrals and follow-through, thereby reducing risks associated with preterm delivery and increasing optimal pregnancy outcomes. The prior process lacked continuum of care strategies resulting in client dissatisfaction, declining numbers of clients receiving prenatal care, and litigation issues between health department clients and private providers. Process implementation resulted in outstanding customer/staff satisfaction, cost savings for revenue to the CHD, and a partnership between private and public health sectors unsurpassed by any other county health department in Florida. Implementation of this program meets the needs of all Brevard’s pregnant women and has strengthened the provision of ante partum care for indigent women. Brevard women now enjoy 100% accessibility to high-quality maternity care, including, efficient, timely, and customer-friendly prenatal care, delivery services, and post-partum care. High client satisfaction is exhibited by low litigation numbers and as measured in terms of improved pregnancy outcomes. Compliance with prenatal care is at an all time high; very few clients miss even one prenatal visit, client/staff/provider satisfaction with office visits, hospital intervention, delivery and postnatal care is high. Brevard County exceeds Healthy People 2010 targets in terms of fetal death rates and infant mortality. As of 2001-2003, Brevard is closing in on the 2010 target of 90% at 86.7% for pregnant women receiving early prenatal care. The rate of neonatal deaths and post-neonatal deaths are declining, and Brevard exceeds state goals in: average number of prenatal visits, numbers tested for HIV, low and very low birth weights, percent of breastfed infants, births to teens and percent of teens having a repeat birth. Lastly, by addressing liability issues voiced by the private sector, Brevard has been successful in retaining more private practice obstetricians than counties with similar demographics and resources.