Bringing baby home: a comprehensive case management program for obstetrical services.

In April 1992, PCA Health Plans of Texas, Inc., instituted a comprehensive program of case management, patient education, utilization management, and home health services designed to both improve clinical outcomes of pregnancy and reduce the costs of delivering obstetrical, perinatal, and neonatal services in an HMO.

PCA Health Plans is a network-model HMO with a membership of approximately 113,000 commercial members and 25,000 Medicaid members. Both memberships have a young population and a high volume of obstetrical cases. Based on prior studies of utilization patterns for normal obstetrics and of risk factors associated with pregnancy complications, a program called Bringing Baby Home[TM] was designed to address both issues, using a multidisciplinary approach of patient and provider education, early detection of high-risk mothers, enhanced home health care benefits, and comprehensive case management by specially trained nurses.

Through use of PCA's referral system, all pregnant women are enrolled in the program and are tracked to see that they avail themselves of early prenatal care. All women are also administered a questionnaire designed to identify those at risk for complications. Those identified are placed under case management that involves site visits, education, support, and close follow-up by nurses and the institution of obstetrical home health care when appropriate, including home use of oral and subcutaneous tocolytics, monitors, and skilled visits as medically indicated. Intensive patient education is also undertaken to encourage the patient's participation in the effort to prevent preterm births and other complications.

In addition to traditional home health interventions, such as education, monitoring, and medication administration, nonmedical benefits, such as transportation assistance, homemaker assistance with cooking and cleaning, and child care can be delivered in those instances where such services will obtain better patient compliance with physician recommendations.

For pregnant members not under case management, education classes are sponsored by the HMO at participating hospitals and other facilities. Patients attending these classes receive education on normal pregnancy and on the signs of potential complications and are informed about the hospital routine for normal obstetrical patients and about PCA's program for discharge planning and extended postdischarge benefits. Present at these classes to answer questions are a case management nurse and an HMO obstetrician and/or pediatrician. Patients attending one of these classes are eligible to receive gifts, such as an infant care seat.

Following admission to the hospital, all patients receive on-site concurrent utilization review by health plan nurses and are instructed in postdischarge benefits, including one day in home follow-up by a home health nurse experienced in both obstetrics and neonatology and early follow-up with the baby's designated pediatrician. Additionally, mothers going home within the health plan's guidelines (one-day stay for vaginal and two days for C-section delivery) receive a voucher entitling them to free maid service at a time of their choosing. Early home health nurse follow-up is designed to allow early assessment for any complications in either the baby or the mother.

The HMO's contracted physicians were involved in development of the program and have supported our efforts. The program has received excellent acceptance by the patient population and is now considered a marketing advantage for the HMO.

Analysis of data collected in the first 12 months following inception of the program reveals a 24 percent reduction in the number of neonatal bed days and that 86 percent of women with vaginal deliveries were discharged from the hospital within one day and 72 percent of those undergoing C-section deliveries left within two days. To measure for possible adverse consequences to normal neonates resulting from these early discharges, the readmission rate for neonates was determined for the nine months following inception of the program. The data revealed a 50 percent decrease in the rate of neonatal readmissions, providing some reassurance that early discharges were compatible with good neonatal outcomes.

Cost savings from this program have amounted to $1.3 million, after accounting for administrative costs associated with its implementation.

In summary, the program has documented that innovative use of home-based health care delivery and comprehensive case management can have a substantial impact on both patient outcomes and health care costs.

Bruce A. Weiss, MD, MPH, is Executive Vice President, Medical Affairs; George F. Smith, MD, is Vice President of Medical Affairs; and Kathie Bacque, RN, is Manager, Obstetrical Case Management, PCA Health, Plans of Texas, Inc., Austin.