A Model for the Provision of Prenatal Care

1. A Model for the Provision of Prenatal Care A partnership between a private physician practice, a community hospital and a local health department to provide prenatal care to a vulnerable population. Ann Addison, CNM Mimi Collins, CEO The Longstreet Clinic, PC Georgia Perinatal Association 2005 Annual Conference

2. Hall County Population GrowthFrom Norton Agency – “Native Intelligence Forecast” Georgia Perinatal Association 2005 Annual Conference

3. Changing DemographicsFrom Norton Agency – “Native Intelligence Forecast” Georgia Perinatal Association 2005 Annual Conference

4. About Hall County(from US Census Bureau) • Population of 156,101 based on 2003 Census estimates • 71% of population is White – not of Hispanic/Latino origin • 19.6% of population is of Hispanic/Latino origin • 7.3% of population is Black or African American • 16.2% of population is comprised of Foreign Born Persons versus 7.1% for all of Georgia • 20.7% of the population speaks a language other than English in the home. • 12.4% of the population in 1999 was below poverty level Georgia Perinatal Association 2005 Annual Conference

5. Department of Community Health2002 Data • 23,598 Medicaid Recipients in Hall County • 4621 Peachcare for Kids Recipients in Hall County Georgia Perinatal Association 2005 Annual Conference

6. Northeast Georgia Medical Center Statistics • 3943 deliveries in 2004: • 32% of which were to Hispanic mothers • 55% of which were to patients covered by Medicaid Georgia Perinatal Association 2005 Annual Conference

7. Initial Goal of the Prenatal Program The initial goal of the program was to provide a mechanism for delivery of low risk emergency room walk-in patients. Georgia Perinatal Association 2005 Annual Conference

8. 457 deliveries of these only 53 had no PNC Patients delivered with no PNC drops to 35 per year 1065 women treated in the program. - 969 babies delivered 344 walk in deliveries with no PNC 1987 1991 1995 2004 The Longstreet Clinic takes over program and employees CNMs. TLC physicians manage program with HHD. TLC Ob physicians move to a more integrated CNM/MD model for all patient care. NGMC Contracts for CNMS to provide intrapartum care for low risk walk in patients. Program evolves into providing prenatal care at HHD. High risk patients cared for by Ob Medical Staff through a loose arrangement/commitment. Georgia Perinatal Association 2005 Annual Conference

9. The Partnership Hall County Health Department Prenatal Clinic Provides partial funding for Provision of Prenatal & Antepartum Care Provides Obstetrical Medical Care Provides Stipend for CNM Staffing HD Hospital Services Georgia Perinatal Association 2005 Annual Conference

10. TLC Obstetrical Practice • 8 Obstetrical physicians • 10 CNMs • 4 Practice Locations (Gainesville, Baldwin, Dahlonega, Hall County Health Department) • Attends 70% of all deliveries at NGMC. • MD/CNM relationship is based on a collaborative model. • TLC has attended: • 2003 – 2638 deliveries • 2004 – 2716 deliveries • 2005 – 1400 deliveries - YTD June Georgia Perinatal Association 2005 Annual Conference

11. About the Prenatal Program Patients • 94% - 95% of the patients cared for in the program are Hispanic. • Most do not qualify for Medicaid or other payment sources. • Many are non-English speaking. • Most are married. • Many are working and/or their spouse is working in the community. Georgia Perinatal Association 2005 Annual Conference

12. Goals of Health Department • Reduce number of women without access to prenatal care • Increase number of these women who enter care within 1st or 2nd trimester • Improve Health Statistics: • Increased Birth Weight • Reduced Infant Mortality • Improve Health Status of Newborns Georgia Perinatal Association 2005 Annual Conference

13. Goals of Physicians • Improve integration between the health department, physicians and the hospital to: • Reduce number of “walk-ins” into ER • Limit financial losses associated with providing care to this population • Improve flow of needed clinical information to the hospital/attending physician • Manage risk of physicians • Improve outcome of patients and their newborns Georgia Perinatal Association 2005 Annual Conference

14. Goals of Hospital • Reduce deliveries with no prenatal care • Manage hospital risk associated with a high risk population • Reduce financial losses associated with providing care to this population • Improve health status of newborns Georgia Perinatal Association 2005 Annual Conference

15. Hospital “Walk-Ins”(patients presenting to ER for delivery with inadequate prenatal care) • Hospital Deliveries • 2023 deliveries 1987 • 3943 deliveries 2004 • Walk – ins • 344 walk-ins 1987 • 40 walk-ins 2004 • Today, ¼ of the women delivering in our community are cared for through the Prenatal Program Georgia Perinatal Association 2005 Annual Conference

16. Patient Enrollment • In 1996, the Prenatal Program enrolled an average of 55 new Ob patients per month. • Today, the Program enrolls 80-90 new Ob patients per month. Georgia Perinatal Association 2005 Annual Conference

17. Prenatal Program Statistics Georgia Perinatal Association 2005 Annual Conference

18. Entry Into Care Georgia Perinatal Association 2005 Annual Conference

19. Funding • Majority of patients accessing care at the Health Department do not qualify for Medicaid or any other payment source. • Patients are asked to pay $1000 for prenatal care regardless of when they enter program. • Patients that cannot pay may qualify for assistance through Babies Born Healthy or Indigent Care Trust Fund monies. • Most Patients will qualify for Emergency Medicaid at some point in pregnancy or at delivery. Georgia Perinatal Association 2005 Annual Conference

20. HOWEVER; • There are a group of patients that: • Do not pay for prenatal package, AND • Do not qualify for any support. • TLC bills patient directly for MD visits and ultrasounds beyond first 2, if the patient has not qualified for Emergency Medicaid. • Hospital bills patient for additional labs. • Due to timing and compliance of patients, some patients do not qualify for Emergency Medicaid at any point. Georgia Perinatal Association 2005 Annual Conference

21. Improve Clinical Outcomes This group of women will deliver at our community hospital whether or not they receive prenatal care – By working together, clinical outcomes are improved which helps to reduce and manage risk to the providers which in turn controls financial impact to our community. Control Financial Impact Manage Risk Georgia Perinatal Association 2005 Annual Conference

22. Comprehensive Prenatal Package • Scheduled and problem Ob visits • Routine NOB Labs: • ABO & Rh • ABS • RPR • HBsAg • Rubella • Urine Culture • Additional Labs • 1 hour glucose screen • Hemoglobin • ABS @ 26-28 weeks for Rh negative women • Up to 2 ultrasounds • Prenatal Vitamins and Iron (if needed) Georgia Perinatal Association 2005 Annual Conference

23. Additional CostsNot Included in Package • Triple Screen • 3 Hr GTT • PIH Labs • HgbA1C • 24 hour urine collection for protein • GBS culture • Non-stress testing • Additional Ultrasounds • Rhogam for Rh Negative women • Level II Ultrasounds Georgia Perinatal Association 2005 Annual Conference

24. Initial Contact • Pregnancy test • Eligibility criteria • Prenatal vitamins • WIC Georgia Perinatal Association 2005 Annual Conference

25. New Ob Visit • Medical History • Surgical History • Obstetric History • Family History • Social History • Physical Exam • NOB Labs • Identification of Problems • Plan of Care Georgia Perinatal Association 2005 Annual Conference

26. Certified Nurse Midwifes • Available for consultation • Staffed in Clinic 5 days per week • CNM visit at 28 weeks after 1 hour glucose screen is completed • CNM visit at 40 weeks and weekly thereafter • See any patient who is considered at risk • Manage prenatal, intrapartum and postpartum care • Independently • In collaboration with physician • Refer for medical management Georgia Perinatal Association 2005 Annual Conference

27. Staffing at the Health Department from TLC • CNMs 5 days per week • Ultrasonographer 4 days per week • NSTs 5 days per week • MD 1 day per week • Certified Diabetic Educator and Nurse Practitioner 1 day per week • Is admitting physician for Health Department patients. Georgia Perinatal Association 2005 Annual Conference

28. Challenges that Face Us • Late to Care • Absence from Care • Undocumented Women • Limited Political Support • Potential Medicaid Reductions • Reductions to State Budget • Potential Increases in Uninsured • Continued cultural barriers to accessing care in a “traditional setting” Georgia Perinatal Association 2005 Annual Conference

29. Why is this Program Important? • Access to quality health care • High-quality, cost-effective prenatal care • Increase in number of women who receive prenatal care • Decrease in number of women who are “walk-ins” • Decrease in percentage of sick and low birth weight infants • Decrease in percentage of infants admitted to NICU • Identification of women with chronic health problems Georgia Perinatal Association 2005 Annual Conference

30. Our Outcomes • Hall County is consistently below the State rate for Infant Mortality Rate. Georgia Perinatal Association 2005 Annual Conference

31. Family Connection Partnership2004 GEORGIA KIDS COUNT - REPORT Georgia Perinatal Association 2005 Annual Conference

32. According to Georgia Family Connection Partnership, Hall County’s 2004 Healthy Start Index is 90.9% compared to 71.4% for the rest of the State of Georgia. Georgia Perinatal Association 2005 Annual Conference