Healthy Addition

Kim Brew
Kim Brew is a Project Manager for Blue Cross Blue Shield of Florida.

Introduction

Healthy Addition^®, created by BCBSF, is a voluntary prenatal education and early intervention program that provides information and assistance to expectant women. The program emphasizes early screening, member education, and monitoring of expectant mothers who have risk factors that may indicate potential problem pregnancies and premature deliveries.

Since 1992, when Healthy Addition was implemented statewide, the results of the program have been very positive. The average gestational age of premature births increased from 33 weeks to 35 weeks, the prematurity rate decreased from 11% - 8%. To a fragile neonate, every week that they can be kept in utero is extremely important.

Historical Overview

Perinatal health is an important issue for all women in their childbearing years (age 15-44). Every year, nearly 4million babies are born in the United States. Approximately 13% of the babies are born to teen mothers, 7% are low birth weight babies (LBW - less than 2500 grams or 5.5 pounds), 1.3% are very LBW (less than 1500 grams or 3.3 pounds) and more than 11% are pre-term births. These numbers show that an estimated 33% of the babies born in the United States fall into an identifiable risk category.¹

These births are not only "at-risk" from a health standpoint, but place the families at a significant financial risk. Delivery costs for complicated births range from $20,000 to $400,000 per baby, compared to about $6,400 for an uncomplicated birth. The lifetime medical costs for one premature baby are conservatively estimated at $500,000.²

As early as 60 years ago, federal public health programs were initiated to address the issue of improving health care delivered to pregnant women. These programs were established mainly for the impoverished population of women. Aside from a few pioneering managed care programs such as Kaiser Permanente (founded in 1945), prenatal wellness programs were not regularly offered to women by indemnity insurers or other payers until recently.³

Presently, organized physician groups and managed care organizations have recognized their excellent position to offer high-quality health management initiatives to expectant mothers. Most of the major managed care plans have developed cost-effective outcome based programs. The goal of all of these programs is to improve health outcomes for mothers and babies through early prenatal access and education.

In 1991, Florida ranked 47^th in terms of unhealthy births. In response to this disturbing statistic, BCBSF began the development of the Healthy Addition program. Healthy Addition is a voluntary prenatal education and early intervention program that provides information and assistance to expectant women. The program emphasizes early screening, member education, and monitoring of expectant mothers who have risk factors that may indicate potential problem pregnancies and premature deliveries.

Description Of Program

The Healthy Addition program consists of initial case identification; pregnancy risk screening/rescreenings; referral to high-risk monitoring nurses when appropriate; education; coordination of care with the expectant mother's obstetrician; case management; home care as needed; automated tracking system; and evaluation and outcome measurements (clinical and financial).

The Healthy Addition nurse conducts a telephonic assessment using a screening tool that asks women specific questions about previous pregnancies, other high-risk deliveries, chronic disease, medication history, including use of infertility drugs, exposure to toxic substances, etc. Women who do not screen positive for a potential risk are re-screened at 28 - 32 weeks gestation. Frequently pregnant women do not become high-risk until later in the pregnancy. Highlights of the initial screening tool are listed in Table 1. Responses are weighted as major or minor risk factors depending on the question and computed score. The score determines the level of risk.

If a member is determined to have a potentially high-risk pregnancy, based on the responses recorded during the screening, they are enrolled in the high-risk component of the program. A member may also be referred to the program if the prescreening nurse believes a mother could benefit from high-risk monitoring or if a woman's physician thinks high-risk monitoring will help her throughout her pregnancy.

When the member is determined to be high-risk, Healthy Addition nurses send the member's obstetrician a letter notifying them of the results of the screening and enrollment into the program. The nurses request any feedback from the physician regarding how the program can best meet the needs of the member and physician.

While the nurse is conducting the initial screening she also provides education on the signs and symptoms of pre-term labor to every participant, regardless of risk status and stresses following the physician's treatment plan.

The educational component of the program is critical in the prevention and management of pre-term labor (PTL). The women are educated in the signs and symptoms associated with pre-term labor, pre-term birth prevention strategies and the effects of rest, work, proper nutrition, activities, and prevention of UTIs on the occurrence of PTL. Healthy Addition nurses also mail each participant the American College of Obstetricians/Gynecologist's (ACOG) pamphlet titled "You and Your Baby", a brochure promoting the value of Healthy Addition, and a magnet identifying signs and symptoms of pre-term labor.

Monitoring The Healthy Addition Participants

Members referred to the high-risk monitoring nurses are followed telephonically at weekly, biweekly or monthly intervals, depending on the woman's needs. The nurses offer educational interventions, emotional support, and encourage the mother to contact her physician for questions or problems outside the nurses' scope of interventions.

The nurses stay in close contact with the member's obstetrician throughout their participation in the Healthy Addition program. Case management is also a critical component of Healthy Addition. As the nurse regularly contacts the high-risk women, they are able to alert the physician to potential problems that may need intervention. They can assist the physician in the care management through coordinating needed services, such as Home Uterine Monitoring.

As an example, according to a study published in ACOG by M.J. Corwin⁵, Home Uterine Monitoring in conjunction with tocolytic therapy for pre-term labor, was extremely beneficial in improving pregnancy outcomes based on a number of clinical criteria, including the pre-term birth weight, NICU admission rate, and NICU length of stay (Table 2).

Physician Involvement

Physicians are encouraged to continually supply the Healthy Addition nurses' feedback that would continue to maintain the quality of the program. The program has been designed to be easily accessible to physicians. The nurses are available to assist the physician and to coordinate resources the patient may need from the physician such as home health care or durable medical equipment.

Program Evaluation

The managed care companies which have prenatal care programs have developed various methods of evaluating the effectiveness of the programs. BCBSF has developed a database and tracking system specifically for Healthy Addition. Indicators have been established to assist in the evaluation process and in the reporting of operational, quality/clinical, utilization and financial outcomes of the program. Examples of these indicators are identified in Table 3.

Results

As mentioned in the previous section, there are many ways to evaluate the outcomes of a prenatal high-risk program. The results discussed below are indicative of the benefits that have been achieved through Healthy Addition.

Figure 1. Average Gestational Age Of Premature Births And Prematurity Rate Of Healthy Addition Program	Figure 2. Estimated NICU Costs

Before the Healthy Addition program was implemented the average gestational age of premature births was 32.6 weeks., with a prematurity rate of 11 %. A premature birth is considered a birth less than 37 weeks gestation. The prematurity rate is determined by dividing the number of premature births by the total number of viable deliveries.

In 1992, the year that Healthy Addition was implemented statewide, the average gestational age of premature births was 33 weeks, with a prematurity rate of 11%. By 1998 the average gestational age of premature births improved to 35 weeks. The prematurity rate between 1992 and 1997 also decreased from 11% to 8% (Figure 1).

Every week closer to the full gestational age of 38 - 40 weeks means the probability of a better clinical outcome for the baby and less cost to the health plan. In Figure 2 the estimated NICU costs associated with the gestational age at birth is demonstrated.

As shown in Figure 2, the estimated difference in NICU cost between a premature birth at 33 weeks and 35 weeks is approximately $28,000/birth.

Summary

Health plans that have implemented prenatal wellness programs, which emphasize wellness, education and risk identification of members at risk for pre-term labor have contributed to lowering the pre-term birth rate. Through the coordinated efforts of the Healthy Addition staff, the OB physicians and members, the program has been able to improve the outcomes of the high-risk mothers and their babies. The program staff is continually striving to find new ways to improve the program for the members. Member satisfaction is high as well as overall support from the physician community.

REFERENCES

1. "Perinatal Statistics by Maternal Race." United States, 1994. March of Dimes Perinatal Center. 1997.
2. Lewit EM, Baker LS, Corman H, Shiono PH. The Direct cost of low birth weight. In: The Future of Children. Vol. 5, no.1. Los Altos, CA: The David and Lucille Packard Foundation, 1995: 35-36.
3. Gore MJ. Prenatal and Postpartum Programs Save Money. A Review of Marketplace Practices. 1998 Wellness & Prevention Sourcebook.
4. Cohen Arnold, M.D., Herpel, Georgia. Maternity Program Improves Perinatal Outcomes for Aetna U.S. Healthcare's Youngest Members
5. Corwin MJ, Mou SM, Sunderji SG, Gall S, How H, Patel V, Gray M. Multicenter Randomized Clinical Trial of Home Uterine Activity monitoring: Pregnancy Outcomes for all Women Randomized. Am J Obstet Gynecol, 1996; 175: 1281-5.

September, 1999/ Jacksonville Medicine

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