PERINATAL CARE How to Establish / Perinatal Services 4 in Community P Health Centers \ 4 = 1 > = ali eo oy Ci 3 198m U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Vv ¢ Health Resources and Services Administration Vo ~ As J PERINATAL CARE Lo a. } { | | How to Establish Perinatal Services in Community Health Centers August, 1985 Prepared by John Snow, Inc. under contract with the Bureau of Health Care Delivery and Assistance U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Health Resources and Services Administration Bureau of Health Care Delivery and Assistance Division of Primary Care Services T1264 £2.02. I. II. III. IV. VI. II. III. VI. TABLE OF CONTENTS Introduction and Overview Planning Perinatal Care Services Staffing Perinatal Care Services Supporting Programs and Services Systems Supporting a Perinatal Program Delivery Services APPENDICES Selected Bibliography Organizational Resources Regional Program Guidance Memo 84-52; Perinatal Activities in Primary Care Projects Standards for Prenatal Care American College of Obstetricians and Gynecologists (ACOG) Categorization of Perinatal Services R G90 Tyg de hd Vy — { UIs & me SN SA A WJ Pages 1-5 7-16 17-29 31-45 47-72 73-80 81-86 87-92 93-98 99-114 115-120 I. INTRODUCTION AND OVERVIEW A. Importance of Perinatal Care Services Community health centers with a strong perinatal program have tremendous potential for positively impacting the physical and mental health of mothers, infants and families. The benefits are indisputable. Women and infants who receive early, consistent prenatal care, and have access to specialized services during the pregnancy, labor ard delivery, and post partum period have better pregnancy outcomes and better long-term health than women and infants who do not receive comparable services. The Surgeon General’s "1990 Objectives for the Nation" czll attention to the critical importance of early and ongoing perinatal care. The following objectives have been established: Objective 1: Infant Mortality o By 1990, the national infant mortlity rate (deaths for all babies up to one year of age) should be reduced to no more than 9 deaths per 1,000 live births, with no county and no racial or ethric subgroup having an infant mortality rate in excess of 12 deaths per 1,000 live births. Objective 2: Low Birthweight Rates o By 1990, low birthweight babies (those weighing 5.5 pounds at birth or less) should constitute no more than 5 percent of all live births, and no county and no racial or ethnic subgroup of the population should have a rate of low birthweight infants that exceeds 9 percent of all live births. Objective 3: Early Prenatal Care o By 1990, 90 percent of all pregnant women should obtain prenatal care within the first three months of pregnancy. Going beyond the undeniable health benefits, CHCs lave further opportunity of providing rewarding birth experience for their patients. CHC perinatal programs can be culturally sensitive, provide parenting education and support and linkages with other services, all of which enhance the birth experience and positively impact the mental and physical well-being of mother, infant and family. The challenge facing CHCs is how to provide this critically important service given limited financial and other resources in today’s environment. This manual discusses some of the options available. B. Purpose of Manual This manual has been developed to assist Community Hezlth Centers (CHCs) in organizing and operating high quality, efficient perinatal care services for the communities they serve. The contents of the manual are intended to complement and elaborate on the policies and principles outlined in the Bureau of Health Care Delivery and Assistence (BHCDA) Guidance Memorandum No: 84-52 "Perinatal Activities in Frimary Care Projects," which is included as Appendix III. It is designed primarily for larger health centers, specifically those with more than 120 perinatal patients each year, but may be helpful to all health centers. It primarily addresses programmatic and administrative issues related to perinatal care in CHC rather than clinical protocols. It also establishes minimum expectations for what services should be provided and discusses the many options open to a center for structuring and supporting a comprehensive perinatal service within a total system of perinatal care. Specifically, the manual presents information and techniques for plannirg perinatal services, discusses staffing options and suggests supporting systems and programs. Vhile minimum expectations are established, the manual offers many service delivery options which satisfy these expectations. It allows for a great deal of health center flexibility and encourages creativity within certain basic standards. C. Definitions of Perinatal Care Services For purposes of this manual, perinatal care services are defined as medical, educational, nutritional, social work and suppcrt services provided to women and infants from conception through the mother’s post-partum care and the child’s initial newborn care, typically 4-6 weeks following delivery. Perinatal services encompass prenatal, labor and delivery, postpartum and early pediatric care for both uncomplicated and high risk pregnancies. Services may take place within a CHC or in other facilities which are part of the perinatal care system. A major goal of the manual is to focus on the importance of providing continuous care for the mother and baby throughout all phases of the perinatal cycle. The importance of beginning care early, preferably in the first trimester of pregnancy, of maintaining compliance with American College of Obstetricians and Gynecologists (ACOG) standards and of preconception counseling and interconceptional family plannirg are also emphasized. Finally, the manual focuses on the special needs of high risk patients in prenatal, delivery and postpartum care. D. Content of Manual The manual is divided into five sections: Planning Perinatal Care Services; Staffing; Supporting Programs; Supporting Systems; and Managing Delivery Services. There is also a selective, annotated bibliography and list of organizational resources which provide information and assistance in developing perinatal care services. Each section of the manual provides important information, and health center staff are encouraged to read the entire manual. To assist in reference, however, the highlights of each chapter are noted here: Planning Perinatal Care Services; Section II Page 1. Steps in conducting a needs assessment. 7 2. Relevant data for assessing perinatal needs. 8 3. Techniques for assessing consumer demands and wants 9 for perinatal care. 4. Useful statistics for planning perinatal services. 12 5. Summary of concept of "regionalization" of perinatal 14 services. Staffing Perinatal Services; Section III Page 1. Essential elements in a CHC perinatal program. 17 2. Personnel needed to provide comprehensive perinatal 17 services. 3. Functions needed to be performed for comprehensive 18 perinatal services. : 4. Medical staffing options. 19 5. Cost and productivity considerations in designing 28 ~ perinatal services. Supporting Programs and Services: Creating a Comprehensive are System; Section IV Page 1. Components of a comprehensive perinatal patient 31 education program. 2. Sample education checklist. 34 3. Considerations for group sessions. 35 4. 3. 6. 7. 8. Nutrition and food assistaace (WIC), Social work services. The role of home care in pre- and postnatal care. Effective marketing and outreach. Transportation considerations. Systems Supporting a Perinatal Program; Section VI Considerations in developing perinatal care Incorporating health education and nutrition into Patient tracking during perinatal cycle. Components of a perinatal patient log. Considerations in tracking referrals. Considerations for perintatal medical records. Quality assurance in perinatal care. Transferring information to and from the hospital. Attributes of an optimal system for providing - appointment systems. 2. prenatal appointments. 3. 4. 5. Sample perinatal patient log. 6. 7. Sample referral tracking form. 8. 9. Principle risk factors. 10. 11. 12. Charging for perinatal services. Delivery Services; Section VI 1. routine delivery services. 2. Strategies for overcoming barriers to providing delivery services. 36 39 41 42 44 51 52 54 56 58 59 62 64 67 69 Page 73 75 3. 4. 5. Definitions of high risk deliveries. Assuring coverage for high risk deliveries. Birthing centers. 77 78 79 II. PLANNING PERINATAL CARE SERVICES A. Overview Every health center, whether developing new perinatal services or expanding or enhancing existing services, should go through a planning process to assure that appropriate services are available to its target population. This planning process for perinatal services includes the same basic steps as general program planning: @ projecting the need and demand for perinatal services among the target population; e establishing program goals and objectives and designing services to meet identified needs and demands, and; eo establishing ongoing methods for assessing the program’s success in meeting its objectives and revising the program as necessary. In addition to following this.general process, all planning for perinatal services should be done within the context of the regionalized system of care established in its state. This section of the manual presents information of direct relevance to planning perinatal services in a community health center. It includes statistics for assessing the need for perinatal services in a target population, techniques used in assessing demand, special considerations for CHCs and a discussion of the concept of regionalization of perinatal services. B. Needs Assessment Methodology for Perinatal Care A needs assessment methodology has been developed for community health centers by the Bureau of Health Care Delivery and Assistence in the Regional Program Guidance Memorandum 85-2 (1/4/85). Individual worksheets are provided which offer a step by step approach to projecting the need for services within a health center primary service area. This manual will only summarize the major steps involved in any needs assessment and present information relevant for projecting the needs for perinatal care services. The six sequential steps of a needs assessment are: 1. Define the service area of the site. 2. Describe the economic status and other demographics of the patient population. 3. Estimate the need for services within the service area. 4. Establish the existing supply and capacity of services. 5. Analyze the projected need vs supply of services. 6. Identify special health status needs. The BHCDA Guidance Memorandum details these overall steps and provides a methodology for collecting, summarizing, and interpreting required data. The preparation of a needs assessment for the overall primary care program should contribute greatly to simplifying a perinatal program needs assessment since much of the relevant data will be readily available. A perinatal program needs assessment should concentrate on the medical, nutritional, educational and support services needed during pregnancy and infancy. As with any needs assessment, it should identify overall needs in the target population and identify special needs of high risk population groups. The particular information of interest in developing a perinatal program needs assessment are: ° Number of females ages 15 through 44 in the service area. The 15-44 breakdown is routinely used in relation to perinatal services as it is the age breakdown most closely related to a woman’s childbearing years for which data is usually readily available. It is the age breakdown used by the Census Bureau, the National Center for Health Statistics and BHCDA on the BCRR. Younger ages may also be considered as appropriate. However, standard data may be more difficult to obtain. ° Percentages of females ages 15 through 44 to the entire population of the service area. Also, percentages of females ages 15 through 44 who are health center users to the entire population of CHC users. High percentages may indicate a greater than average need for perinatal care services within a population. Again, younger populations may be reviewed as appropriate. ° Fertility rates (live births per 1000 women age 15-44) and crude birth rates (live births per 1000 total population) for the state in which the CHC is located, broken down whenever possible for age groupings, socioeconomic status, and ethnic composition of the health center service area. Since fertility rates and birth rates often vary by these factors, it is important that the CHC attempt to use fertility rate and birth rate statistics which will closely approximate the actual (though probably unobtainable) statistics of the service area population. Particular effort should be made to obtain area fertility rates and crude birth rates for adolescents in the service area including very young adolescents (under 15), middle adolescents (15-17), and older adolescents (18-19). CHCs with strong perinatal programs serve a substantial percent of the adolescent population and must tailor services accordingly. Local hospitals, planning agencies, MCH and family planning agencies, and state departments of health vital statistics and research may be able to provide appropriate rates to community health centers. State or county fetal death (spontaneous fetal losses from recognized pregnancies), neonatal (deaths within the first 28 days after birth) and infant mortality and morbidity rates (deaths or illness under one year) at present and averaged over the last 3 to 5 years. Again, these should be broken down whenever possible for age, socioeconomic status and ethnic composition as the rates often vary greatly ty these factors. Higher than average infant mortality and morbidity rates may indicate a need for additional or specialized perinatal care services or increased emphasis on early care. Rates of low birth weight infants (less than 2500 g.) and very low birth weight infants (less than 1500 g) in the area broken down by age, ethnicity, and socioeconomic status. High incidence of low birth weight infants may indicate inadequacies in the perinatal care system. Review of state and local MCH activities in the service area. The number of hospitals, public health department services, clinics, HMOs, private practices, and health centers currently supplying perinatal care services to the service area population. Also, an assessment of the appropriateness of the services presently supplied within the health center service area. Special consideration should be given to barriers to service for special populations and/or socioeconomic groups such as Medicaid population, adolescents, migrants, non-English speaking groups, etc. A description of "regionalization" of perinatal services within a health center service area. The concept of regionalization allows area providers to coordinate their programs to assure appropriate levels of perinatal care for all women and infants. Regionalization of services include primary, secondary, and tertiary care facilities and formal referral systems along with effective transportation and education programs. Additional resources available to the CHC for high-risk patients including WIC programs, specialized testing and laboratory, genetic counseling, high risk maternity centers, emergency transport, neonatal intensive care centers, and public health nursing and visiting nurse associations. C. Demands Assessment Methodologies The purpose of a demand assessment is to focus on what the patient population wants and/or expects from the CHC perinatal care program rather than on the population’s clinically determined "need" for services. All demand assessment methodologies utilize tools for surveying the target population’s opinions and preferences, past usage of services, and anticipated usage of new services. A perinatal program must be designed to appeal to the target population not just to the center staff. The demand assessment helps assure the program is appealing to patients. A useful first step in beginning to assess demand for perinatal care services is to take a close look at the present level of patient satisfaction at the health center. While patient satisfaction levels will not reveal the preferences of the general target population, an analysis of questionnaires and patient complaints over the past year or two may reveal some systems which are the prime targets for patient complaints and which will need improvement before beginning or expanding a perinatal care program (examples: front desk, billing or appointment systems, medical records). Since the success of the perinatal program is very much dependent on the effective operation of supporting health center programs, some "housecleaning" or problem solving should be initiated at this early stage of program development. The three most common methods for assessing demand for services are written surveys, telephone interviews, and focus discussion groups. Each can be conducted with specific segments of the target population, e.g., current users, high risk non-users and so forth. All of these methods provide information used to accurately project program utilization rates and to design specific features of the perinatal program (hours, education topics/techniques, preferred hospitals for delivery, etc.). Each of the methods will be discussed briefly. Written surveys are perhaps the most inexpensive method for health centers to gather pertinent information from target population patients. The survey form can be individually tailored to the questions of most concern to the health center and either mailed to a sample of the target population (examples: women in target area with no children, all health center users ages 15-44 with one child, all pregnant health center women ages 15-44) or handed to targeted population health center patients before an appointment. Questions should be phrased simply and the patient’s answer should be checked off a limited list of possible choices. Completion of a written survey should only take 5 to 10 minutes of time, so the number of questions should be limited. Some of the interesting questions which can be explored through a written survey are: ° What hours are most convenient for perinatal appointments? ° What hospitals are preferred for deliveries? ® What does the patient like most about existing programs at the health center? What does she like least about existing programs at the health center? ° If a new perinatal program is beginning, will the patient use the health center’s perinatal services in the future? ® Is transportation to the center for the perinatal visits or 10 educational sessions a problem? ° What are the patient population’s attitudes about medically needed perinatal care? How will these attitudes interfere or act as a barrier to providing services to the group? ° What services in addition to medical care will be utilized by the patient? The same types of questions can be explored through a telephone interview survey with a random sample of present health center users or potential users. The advantage of a telephone survey is that typically more people complete telephone interviews than written surveys. Also, if questions need explanations, verbal interaction between the interviewer and the patient can take place. The disadvantage of telephone surveys is that often many numbers need to be dialed for each successfully completed interview since some telephone numbers will be busy, incorrect, or there will be no answer. Like the written survey, telephone interview questions should be simple and the entire interview should take no more than 5 - 10 minutes. Typically, a completed interview on a 1% to 5X random sample of a target population gives adequate data. A more detailed look at the demand for perinatal care services can be gained through the use of focus discussion groups. The group is composed of six or eight target population women (example: health center women age 15 to 44 with one or more children or women in the at-risk population who do not use the center’s perinatal program) discussing perinatal program features and issues with a health center moderator. Typically, some incentive such as a meal or a small fee and free child care is provided to focus group participants. Issues for discussion can include the questions above and others such as the health center’s image, educational issues, opinions about the level of quality care being provided, etc. The "focus" of the discussion is the groups’ expectations/opinions about perinatal care and preferences for particular services (transportation, reminders/tracking, hours, child care, etc.). The advantage of a focus discussion group is that issues can be explored in more detail through interaction between participants. Often, focus groups give creative solutions or ideas from the patient’s perspective. The disadvantage of focus groups is that the total number of opinions sampled is relatively small (only 12-16 if two focus groups are conducted) so generalizing the opinions of the group to the entire target population may be difficult. Regardless of the particular demand assessment method used, community health centers must understand the patient’s perspective and preferences for an accurate forecasting of utilization of services and program success. We are not suggesting that a community health center design a perinatal care program using only a demand assessment. However, an effective program needs to address any gaps between the projection of perinatal care needs and the demand for services by the population. These gaps can be addressed through careful program design and aggressive marketing, educational, tracking, and referral programs. 11 D. Some Special Considerations in Planning a Perinatal Program The following definitions and statistics may be helpful in projecting the needs and demands for perinatal care services. e The health center delivery rate is defined as: the number of health center deliveries the number of health center female users 15-44 X 100 This delivery rate is roughly comparable to area general fertility rates where the general fertility rate is defined as: the total number of births in an area the number of females 15-44 in area population . X 100 Health centers may expect their delivery rate to vary from between 5-25 percent based on fertility rates in their target populations and the availability of other resources for perinatal care. In general, a health center should expect a delivery rate equal to or greater than area fertility rates, weighted as much as possible to reflect the age and ethnicity, and socioeconomic status of the center’s patient population. A center with delivery rates below area fertility rates should make sure either that their population differs from the general population and has lower fertility rates or that care is being adequately provided by other resources. The national fertility rate in 1980 was 68.4 per 1000 for the total at-risk population (women ages 15-44). The rate was 64.7 per 1000 for the White population and 88.6 per 1000 for the non-White population (88.1 for the Black population). The national rate ranges by state from a low of 51 to a high of 123 per 1000. CHCs nationwide with more than 150 deliveries per year average a delivery rate of approximately 100 per 1000 women ages 15-44. e Many health centers should expect to serve a significant proportion of adolescents in their perinatal program. The definition of an "adolescent" varies. Most nationally available data divides adolescents into three groups; the younger adolescents (under 15), middle adolescents (15-17) and older adolescents (18 and 19). For purposes of designing special programs and providing specialized care, considering C12 adolescents as all those "under 18" is most appropriate. For data analysis purposes and for consistency with the BCRR, however, the "under 20" definition may be most helpful. It is typical for 10-20 percent of health center deliveries to be for patients under age 18. The percentage of women "at risk" for pregnancy is defined as: health center female users 15-44 total medical users X 100 The 15-44 is used because data is most readily available for this age breakdown. It is recognized that health center populations may have younger women at risk for pregnancy. These figures begin to determine the potential need and demand for perinatal care. For purposes of determining trimester of entry into the perinatal system, entry is defined by the date of the first complete medical history and physical exam related to the pregnancy. Health center patients typically enter care later in their pregnancy than the general population. National Center for Health Statistics data from 1982 report 78 percent of White, 60 percent of Black and 61 percent of all other population groups entering care in the first trimester. Health centers average 45 percent of their patients entering in the first trimester. While there are wundcubtedly definitional differences on what constitutes "entry" into the system, there are also undoubtedly real differences with CHC patients often beginning care later than the general population. Early entry into care is critical for optimal health of both the infant and the mother. The American College of Obstetricians and Gynecologists (ACOG) standards calls for all patients to enter in the first trimester (see Appendix III). The Surgeon General’s goal for 1990 is that 90 percent of all pregnant women will enter care in the first trimester. While clearly this is an ambitious goal even for the general population, it is certainly one every CHC must strive to obtain. To move gradually torward this goal, each CHC should establish interim objectives of increasing first trimester entry (for example, increasing first trimester entry 10-15 percent each year). Aggressive marketing and cutreach services to high risk populations, strong internal referral procedures between family planning, pediatrics, pregnancy testing and prenatal care and strong external linkages with other agencies which may diagnose pregnancy like family planning programs and school health programs will all contribute to early entry into the system. A non-high-risk patient entering care in the first trimester and following American College of Obstetricians and Gynecologists visit standards can expect to have 10-12 13 prenatal visits. Health centers can expect higher than average utilization rates as the high risk status of many of their patients will require more frequent visits and increased referral and consultation activity. Even when patients enter after the first trimester, health centers should expect to provide from 10-14 prenatal visits per patient. e¢ A few patients may discontinue care or "drop out" of the CHC system after initiating care. Dropouts are defined as those who leave for other than definable medical or non-medical reasons. Those that experience a fetal death, are referred for more specialized care, or who move out of the area are not considered dropouts. Patients who simply discontinue care or who choose to seek care from another provider, however, are dropouts. Centers should experience dropout rates of no more than 5 percent. A higher figure may indicate serious problems in the program. In any event, centers should make every effort to follow-up on dropouts and assure care is being rendered to the pregnant patient. E. Regionalization of Perinatal Services In conducting perinatal care need and demand assessments and in developing perinatal care programs, CHCs should work within the concept of "regionalization" of perinatal care services. The regionalization concept evolved in the mid-1970s and is promoted in the March of Dimes 1977 publication "Toward Improving the Outcome of Pregnancy: Recommendations for the Regional Development of Maternal and Perinatal Services." Regionalization and the concepts put forth by the March of Dimes are promoted by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Perinatal Care. Regionalization was developed to help assure that high quality, cost-effective, and appropriate perinatal services are available to everyone. In essence, the concept calls for a system of care to be developed for a defined geographic area and population base. Within the geographic area, resources are differentiated according to the complexity of care each is capable of providing. The system is structured so that each region can provide complex and specialized care but that highly specialized and costly services are not duplicated to the point of being inefficient and unable to sustain the patient volume necessary for continued high quality care. More specifically, the regionalization concept defines resources as Level I, II or III depending on the complexity of services each is capable of providing. Appendix V, exerpted from Guidelines for Perinatal Care, presents specific examples of what is expected at each level of care. In summary, Level I units provide services primarily for uncomplicated maternity and newborn patients. Level II units provide a full range of maternal and neonatal services for uncomplicated patients and for the majority of complicated obstetrical problems and certain neonatal 14 illnesses. Level III units may provide care for normal patients but especially provide services for all serious types of maternal-fetal and neonatal illnesses and abnormalities. Level III centers should serve regions with 8,000-12,000 annual deliveries. Regionalization extends to outpatient services as follovs. Level 1: Centers providing risk assessment and care for low-risk prenatal patients, and for those with minor complications. Most of this can be provided by nurse practitioners and nurse midwives under physician supervision and should emphasize preparation for childbirth, general health maintenance, nutrition, infant feeding, and parenting skills. Consultation from Levels II and III specialty physicians should be readily available. Level II: Centers providing a full range of prenatal services for uncomplicated patients. Laboratory services to readily assess fetal and maternal well-being should be available, e.g., urinary estriols, photometric analysis of amniotic fluid, lecithin and sphingomyelin ratios, as well as other diagnostic services such as X-ray and ultrasound visualization of the fetus. Patient education as in Level I and consultation from Level III specialists should be readily available. Level III: The full range of prenatal care for normal and complicated patients should be provided as described for Level II units as well as care for unusual or highly complicated cases. In addition, Level III centers should provide and maintain a highly specialized obstetric and pediatric consultation service with full laboratory facilities for the evaluation of maternal and fetal well-being for all prenatal patients within the region. These consultation services should provide referring physician’s information and advice regarding the further management of the potential or actual high-risk obstetric patient and the high-risk neonate. This medical center should also be involved in providing continuing education, training and evaluation for all levels of care. By putting all levels of services together in a defined geographic area for both ambulatory and inpatient care, and by linking them through a referral and transportation network, a system is created. This approach makes the best use of scarce, expensive personnel, is cost-effective and assures appropriate levels of service are available based on the risk of the mother or infant. State health departments and maternal and child health programs are typically involved in regionialization efforts. Clcse working relationships with the state will assure that CHCs are included in the regionalization system and/or plans for their state. 1 pmbulatory Maternal Health Care and Family Planning Services. E. Barnes, Florence, E.F., Ph.D.Sc., M.P.H., Editor. Americn Public Health Association, 1978, p.l2. 15 It is particularly important for CHCs to develop linkages with the State Maternal and Child Health program. These programs, as noted in the Regional Program Guidance Memorandum 84-52 are significantly involved in developing and implementing a regionalized system of perinatal services. Such a linkage arrangement can be helpful in a number of ways, e.g., establishment of standards and protocols, data gathering and analysis, as a referral source into and from the CHC, and training of staff. 16 III. STAFFING PERINATAL SERVICES A. Overview Community health centers have a number of options for staffing perinatal services. This section discusses some of the major options. The challenge facing each center is to construct a model which best meets the needs and preferences of their patients. Every CHC perinatal program must satisfy five (5) criteria: 1. The center must assure provider coverage for all phases of the perinatal cycle. The phases encompass: a) Prenatal care: including routine, high-risk and emergency services. b) Delivery coverage: including normal and high-risk deliveries. c) Maternal postpartum Care: including family planning. d) Child health/pediatric services: including care. for both well and sick infants. 2. The center must provide adequate office hours to assure easy access to routine care. 3. The center must provide seven-day, twenty-four-hour call coverage for problems and deliveries. 4. The center must have a system for identifying high-risk mothers and infants as well as formalized referral and consultation procedures for all patients whose needs are beyond the capabilities of the center. 5. The center must have a perinatal tracking system to follow all patients throughout the perinatal cycle. There are many different ways to meet these criteria. Centers should consider the needs and demands of their patients, the existing staff and mode of health center operation, community resources available for perinatal care, health center financial and personnel resources, etc., vhen formulating the best role for their participation in a system of care. B. The Perinatal Care Team - In every CHC, perinatal care services will be provided by a range of professionals, each contributing a critical aspect of care. Froviders of perinatal services may include: obstetricians/gynecologists family physicians pediatricians certified nurse midwives 17 nurse practitioners physician assistants public health nurses residents social workers nutritionists health educators or certified childbirth educators e child development specialists The provider team must be supported by other administrative and ancillary personnel such as receptionists, billing clerks, medical records clerks, laboratory and x-ray technicians and so forth. Personnel may te part-time, full-time, contracted or staff. Clearly separate staff are not required in each of these positions. In fact, a single person will typically fulfill a number of functions on the perinatal team. A nurse may, for example, assist a physician during perinatal encounters, conduct prenatal education, manage the patient tracking system, function as hospital liaison or conduct home visits for high-risk patients following birth. Further, it is not necessary that staff be employed solely for the perinatal program. A health educator may be employed by the center to conduct prenatal and childbirth education while also working with the adult, pediatric, adolescent and geriatric patients. Similarly, perinatal reception and billing may be folded into a center’s centralized system. A center may also be able to utilize staff of other agencies to supplement their own staff. Whatever personnel are used, it is important that all aspects of ambulatory perinatal care be covered. Specific functions which need to be staffed include: preconception counseling maternal outreach/marketing medical care for mother and infant prenatal health education childbirth education genetic counseling or referral parenting education appointment scheduling/reception medical records patient tracking and recall hospital/delivery liaison outreach for high risk infants/families social services nutrition counseling interconceptional family planning counselcrs translation services for non-English speaking patients In addition, programs which serve a significant number of adolescent patients should take special care to keep the perinatal care team small and 18 constant. Teenagers seem to respond best to programs where the number of people involved in their care is minimized and where one or two specific people serve as focal points for all their questions (medical and non-medical) both during visits and after hours. Trust is an important component in providing care effectively to teenagers, and this is most easily developed when the teen can identify with only a few pecple. It is also important to remember that perinatal care includes early pediatric care for both well and sick infants and that pediatric personnel are key members of the perinatal team. Pediatric staff should be introduced to mothers by the third trimester. Ideally, individual appointments should be scheduled so initial child health information can be given and the need for early and continuing well child care stressed. If individual appointments are not possible, child health staff should participate in group educational sessions. Health center pediatric staff should visit every healthy newborn in the hospital to perform initial exams, reinforce informaticn on early wvell-baby care and feeding, and stress the importance of well baby visits. Every newborn should also be included in a pediatric tracking system immediately following birth so follow-up can be instituted if initial well baby appointments are missed. Sick newborns will be cared for in Level II or III perinatal facilities. It is still essential, however, that the health center staff share in the care or at least follow up the infant’s progress to assure that, once discharged, the infant receives continuing care through the health center. C. Medical Staff Models for Perinatal Care Services in a CHC Perinatal care services are provided by a range of professionals. Typically, however, overall responsibility for care rests with the primary medical providers of service. For purposes of the manual, medical providers are defined as those professionals who assume responsibility for managing the perinatal patient within the boundaries of their education, training and expertise. Primary medical providers may include obstetricians/gynecologists, family physicians, pediatricians, certified nurse midwives, nurse practitioners, physician assistants, and residents. Because primary medical providers are usually the focus of perinatal care and because they are usually the most difficult and expensive to recruit and retain in a CHC, this section will focus on staffing options for this group. A range of models is presented, each with its major advantages and disadvantages to both patients and CHCs. Many variations on the models presented also exist. 19 Full-time, board-eligible or board-certified staff obstetricians/gynecologists provide prenatal, delivery and post partum services. The same physician staff provide after-hours calls and delivery coverage for all health center patients. Nurse practitioners or physician assistants may assist in prenatal care and after-hours call. At least two and preferably three obstetricians are necessary for this model to work effectively. Pediatric services are provided by staff pediatricians, family practitioners, nurse practitioners or physician assistants. Strengths & Advantages Weaknesses or Disadvantages Same group of staff provides a. Depending on reimbursement, thi prenatal, after-hours, delivery may be a very costly model. and postpartum care for mother Costs may be reduced by use which typically leads to good of nurse practitioners or continuity of care and high physician assistants. patient satisfaction. b. Obstetricians may be Training of staff allows difficult to recruit and them to care for vast majority retain, so high compensation (90-98%) of health center may be necessary. patients so referrals are minimized. OBs usually can obtain admitting c¢. OBs may have limited use in and delivery privileges at most other health center primary hospitals. The center may thus care services. A certain have some flexibility in choosing volume of OB care is the best hospital for patients. necessary to support the two to three physicians required Staff should be readily acceptable to maintain the service. to medical and patient communities. d. Obstetrician/gynecologists If there are enough staff, ‘a strong typically want a mixed full service obstetrical/gynecological practice including high-risk service, including family planning, 0B and gynecologic surgery. can be developed. A health center that uses 0Bs for all perinatal care Health center has complete control may have difficulty of how services are scheduled and providing that mix. This delivered, how call schedules are will negatively effect long- arranged, etc. term retention. 20 2. Full time OB/GYN staff, possibly with assistance practitioners, care. Other contracted physicians supplementing prenatal care, after-hours call. Other health services. Strengths & Advantages Can be done with only one obstetrician. Health center has internal clinical focal point for organizing services, and contracting with and managing part-time staff. Most patients (90-98%) can be taken care of in health center so referrals are minimized. Can provide flexibility in choosing best hospital for deliveries though part-time physicians may restrict choices. Depending on the training and expertise of the part- time physicians as well as the full-time staff, the service may be more or less acceptable to the medical and patient communities. May be a good starting point for building a strong OB practice without excessive investment. 21 covering center from CNMs, nurse provide prenatal care, some deliveries and postpartum or residents may assist in deliveries, and sharing staff provide pediatric Weaknesses or Disadvantages If only one full-time physician, practice will have to be mostly OB. Without diversity and with an an intense schedule, turnover may be high. . Stability of arrangement with part-timers may be questionable. . Depending on role played by part-timers or residents, continuity offered to patients may suffer. Certified Nurse Midwives (CNMs) provide the majority of prenatal, delivery and postpartum care including coverage for after-hours call. Obstetricians, either on staff or consultation and delivery services for pediatric backup provide well baby care. Strengths & Advantages Same group of staff provides a. prenatal, after-hours, delivery and post partum care. May also be involved in well baby care. Continuity is good. b. Strong patient orientation makes CNMs popular with and attractive to patients. This may improve appointment keeping as well as c. early entry for care. Potentially less expensive than a physician-based model. High level of commitment to d. perinatal services means long- term retention of providers "is feasible. Backup obstetricians/ gynecologists can treat more complex OB and gynecology cases. This may increase provider satisfaction and improve long-term retention. 22 on contract, provide backup high-risk patients. CNMs with Weaknesses or Disadvantages May be difficult to obtain delivery privileges at the hospital of choice. May have appearance of "alternative system of care" and be less acceptable to the medical community than physician-based model. Still must have arrangements for physician backup on either a part-time or full- time basis. Recruitment may be difficult especially if delivery privi- leges cannot be okttained. . Patient population will be limited to uncomplicated obstetrics. Other patients will need referral for prenatal management and delivery. Family physicians, possibly with nurse practitioner or physician assistants, provide routine prenatal, normal delivery, postpartum and pediatric care. Depending on volume, staff or contract obstetricians provide care or backup for high-risk patients. Twenty-four hour call coverage is provided by the family practitioners, perhaps in conjunction with obstetricians, nurse practitioners or physician assistants. In some arrangements, high-risk patients may be cared for by the obstetricians under a separate call schedule. Pediatricians provide backup for infant care. Strengths & Advantages Weaknesses or Disadvantages a. Same group of staff provides a. Not practical in locations prenatal, after-hours, post that are dominated partum and pediatric care. by specialties and where Can also perform uncomplica- family practitioners cannot get ted deliveries and assist on delivery privileges. surgical procedures so continuity of care is good and b. Still requires obstetrician(s) patient satisfaction high. on staff or through contractual arrangements for high-risk b. Is consistent with philosophy patients or complicated and organization of service deliveries. Some centers may in a family practice-based still require two or more health center. obstetricians for coverage. c. Should be less expensive than obstetrician-based model. d. Model easily accomodates growing and shrinking demand for perinatal services as physicians can be used in other services. e. Does not require limited access to certain days or times as with part-time obstetricians. f. Perinatal call can be incorporated into center-wide call schedule. g. Recruitment and retention of provider is relatively easy. h. Backup obstetricians can treat more complex OB and gynecology cases. This may increase the satisfaction of obstetricians and improve recruitment/ retention. 23 Part-time obstetricians, usually with private practices, provide prenatal/postpartum services with particular emphasis on high-risk patients. Services may be supplemented by residents, family practitioners, certified nurse midwives, nurse practitioners or physician assistants. A full-time nurse practitioner provides prenatal care and coordinates the programs. Twenty-four-hour call and delivery coverage is provided by the same physicians. Pediatric care is provided by center family practitioners, pediatricians, nurse practitioners or physician assistants. Strengths & Advantages Weaknesses or Disadvantages Is a starting point for a. Center is reliant on part-time building an OB practice physicians who may have without significant investment. differing degrees of commitment to the center and Having a midwife, whose schedules may change. nurse practitioner Consequently, center control or physician assistant can be weak. full-time gives some focus for the program b. May have the appearance of a and a definite point of marginal service to patients contact for the patient. and medical community. c. On-site physician time for routine care may te limited. d. After-hours call and delivery arrangements of part-time physicians may not meet center’s standards. 24 6. Strengths & Advantages Access to highly qualified specialist and Level III perinatal center for high-risk mothers and babies. Can be an integral part of a health center’s commitment to and support from a teaching institution. Potentially less expensive than full-time staff model depending on the arrangements vith the teaching institution. Guaranteed access to staff assures continual coverage. 25 Teaching hospital staff provide prenatal, postpartum and pediatric care through combined use of residents and board certified physicians. and deliveries are handled by residents with teaching staff backup. Call Weaknesses or Disadvantages . Frequently rotating resident staff makes it difficult to assure that health center policies and procedures are adhered to. Teaching needs may take precedence over needs of patients. May have the image of less than top quality because of the training aspect and the frequent rotations. Patients may prefer to seek care elsevhere. D. Selecting a Provider Staffing Model for a Health Center Initial Considerations In theory, medical provider staffing model options are extensive. Every health center, however, has internal and external considerations that limit its real options. Some of these are: 1) Specialty model vs. family practice: A center which relies primarily on internists and pediatricians will most easily incorporate obstetricians and pediatricians as the physician perinatal providers. A family practice-based model will most likely use family physicians to provide perinatal services. Family physicians are less expensive and easier to recruit and retain than obstetricians. Perinatal care will also be more easily integrated with other services if provided by family physicians. Family practices, however, may also choose to use specialists for perinatal care or may choose to combine family physicians with obstetricians for high-risk backup. 2) Area hospital(s) admitting/delivery requirements: Each center should identify the best hospital(s) for delivering its patients. Patient preferences as well as quality of care should be considered. The choice of a provider staffing pattern should be greatly influenced by the types of providers able to gain admitting or delivery privileges at the hospital(s) of choice. While it may be possible to change hospital policies, in the long run it is usually advisable, given a strong commitment, to begin a service with providers who are readily accepted by the hospital and medical community. 3) Use of other than physician primary providers: Other providers include Certified Nurse Midwives (CNMs), nurse practitioners and physician assistants. CNMs can provide prenatal, delivery and postpartum care for a significant proportion of perinatal patients. Nurse practitioners and physician assistants can provide routine prenatal, postpartum and infant care. All are valuable personnel for the provision of perinatal care services. A center which currently uses non-physician providers in its other services will more easily incorporate them into perinatal services. Prior use, however, is not an absolute prerequisite. Many health centers that have chosen not to use nurse practitioners or physician assistants for adult or pediatric services have used them for perinatal services with a high degree of acceptance by both patients and physicians. Use of these providers should be seriously considered as a cost-effective high quality alternative or in addition to physician resources for non-high risk patients. 4) Cost of service vs. available resources: Perinatal services can be very expensive. While it is not always true that the least expensive program is also the most cost effective, some models will require more program resources than others. A center must consider both the potential cost as well as potential revenue before selecting a staffing model. 26 5) Patient and community provider preferences: Tc develop a successful perinatal program, a health center should staff its program with providers that are acceptable to the target population and qualified to meet their needs. E. Full-Time v. Part-Time Staffing Considerations There is a clear trend in CHCs to move to full-time provider staffing of perinatal services. Centers with full-time staff realize the advantages of increased control over administrative and clinical aspects of the service and improved acceptance by patients. It is not always feasible, practical or cost effective, however, to staff a perinatal program entirely with full-time personnel. Many centers continue to use at least some part-time personnel in their perinatal program with excellent results. Some factors to consider when deciding on full-time vs. part-time staffing include: ° A minimum of two and preferably three full-time obstetricians are required to operate a specialty-based practice without additional part-time physicians. If only one full-time obstetrician is employed, other obstetricians will te needed to help out with after-hours and delivery coverage. It will probably also be necessary to use family practitioners, nurse midwives, nurse practitioners, or part-time physicians to augment prenatal care. ° Staffing with obstetricians as high-risk backup for a predominantly CNM- or family practice-based perinatal program also requires a minimum of two full-time OB staff or one full-time staff with part-time contractual OB backup. This is necessary to assure full-time call and delivery coverage for high-risk patients. If full-time obstetrical backup staff is not cost effective, a part-time, contractual arrangement may be preferable. ® Part-time medical provider staff can reduce a center’s fixed costs. This may be an important consideration especially as a program is being developed and patient volume is ur.certain. ® If no full-time physicians are employed for perinatal services, a full-time nurse practitioner or midwife should be employed to coordinate the program and provide reasonable patient access. Adolescent patients particularly need a strong and constant person to coordinate their care. ° Since obstetricians are difficult to recruit and retain, a health center can sometimes attract and keep better qualified physicians on a part-time basis. This consideration must be balanced against the control the center may be giving up and the patient’s perception of staffing at the center. 27 F. Cost and Productivity Considerations The costs associated with developing and operating a perinatal care program are substantial. Board-certified obstetricians are generally the most highly salaried of the primary care specialties. Malpractice premiums for obstetricians, already very high, are predicted to climb substantially in the next few years. Family practitioners and certified nurse midwives who have been somewhat shielded from high malpractice premiums can also expect substantial increases. In some places, malpractice insurance may be difficult to obtain at any price. Further, to provide a comprehensive perinatal program, other providers such as nutritionists, social workers, health educators and nurses are essential, adding to the cost of a program. In highly reimbursed centers, the costs may be recoverable through a strong mix of obstetrics and gynecology including surgery. In centers with significant sliding scale reductions and/or low third-party reimbursement rates, however, the program will always require grant support. In these cases, the more successful the program, the more grant support vill be necessary. No health center should use the high cost of providing perinatal care as reason for providing an inadequate service for the needs of their population. Nevertheless, financial issues must be weighed when determining the type and mix of staff and the structure and size of the program. Fee schedules must be carefully structured to reflect all the costs of providing perinatal services, sliding fee scales and budgeted payment plans should be developed to recover as much income as possible while not deterring patients from proper utilization. Outside, complimentary resources at the state MCH program or other agencies should be drawn upon as much as possible. Finally, health centers may have to make some careful choices on the relative importance of different services given the limitations on available grant support. Perinatal care has been demonstrated to have a direct and permanent effect on the health of both mothers and babies. It should be a priority for all health centers where unmet need is demonstrated. Following are some typical productivity levels which may help in developing a financial plan for perinatal services. Salary levels and malpractice premium are not cited. Extreme variability by location and the rapid increases currently taking place make general figures unreliable. Health centers should contact state and local professional societies, state health departments state and national primary care associations and/or their regional offices for specific information in their local area. ® Obstetricians (in practices with 2-3 FTEs) can be expected to provide perinatal services for 150-225 women each year depending on the nature of the patient population, the use of other providers, and the amount of gynecology services provided. 28 CNMs can be expected to manage prenatal care for 9C to 125 women each year. They can also manage labor for the vast majority of these women and can be expected to deliver 50-75 percent without MD assistance. Put another way, a CNM requires delivery assistance for approximately 25-5C births each year. If the needs assessment estimates an increased number of high risk maternity patients in the community, these numbers may need to be adjusted accordingly. Family physicians can be expected to manage 75-90 prenatal patients each year depending on their interest and other commitments and technical skills. Actual delivery rates vary considerably. 29 IV. SUPPORTING PROGRAMS AND SERVICES: CREATING A COMPREHENSIVE CARE SYSTEM The provision of perinatal care should be comprehensive in nature, providing a broad spectrum of family-centered health services including case finding, screening, prevention, diagnosis, treatment and after-care in a multi-disciplinary team effort working to insure continuity of care. This is especially important as the populations serviced ty community health centers are, in large part, those with the greatest risk for poor pregnancy outcomes. These include minorities and other groups at risk: migrant women, teenagers, women in poverty and new immigrants. Many are in two or more of these high-risk groups. Complex social, economic and ethno-cultural factors are barriers to the utilization of the health care system and negatively effect pregnancy outcomes. To encourage proper use of health services, care must be delivered in a way which takes into account and addresses these barriers to care. How, for example, does one reach a newly immigrated Asian woman vhose culture does not encourage her to use formal health care systems and vho speaks English poorly, if at all? How does one motivate the pregnant teenager to utilize care from authority figures she may resent and help her to prepare physically, emotionally and financially for her baby? The following sections discuss the various non-medical components of a perinatal care program which need to be in place if a center is to maximize impact on pregnancy outcomes. A comprehensive program will include each of these components either as an on-site service or on a referral basis. Depending on the program’s location, the availability of other resources in the community, and the composition of the patient population, some components will be more or less important as on-site program activities. Although it may be impossible for all programs to have individuals on staff to separately cover each program component, these services must be available on a part-time or referral basis. In addition, it is critical that all services are provided by qualified, trained personnel. Program directors need to assure that all perinatal patients are receiving comprehensive, risk appropriate, quality services. Comprehensive services include medical, nursing, social work, nutrition and health education. Staff members providing the services described in this section are an integral part of the perinatal team and should be included in the process of developing, reviewing and revising individual care plans. ‘ A. Patient Education Patient education is most appropriately begun prior to conception. This is an excellent time to detect and manage behavioral risks such as excessive alcohol intake, smoking and nutritional deficiencies. . CHCs must also be closely linked with genetic counseling services fcr high-risk women, including those over age 35. After conception, health education is a critical service for perinatal patients. Each of the following areas must be covered at least once and repeated as necessary, during the perinatal period. 31 1. Description of services and the importance of keeping all appointments; 2. Physical and emotional changes during the perinatal period; 3. Discomforts and warning signs; 4. Symptoms and signs of preterm labor; 5. Fetal growth and development; 6. Drugs, alcohol, tobacco and caffeine use and other lifestyle issues; 7. Perinatal nutrition; 8. Perinatal hygiene; 9. Exercise and work during the perinatal period; 10. Availability of resources in the community including food stamps, VIC, Medicaid, etc; 11. Preparation for and description of labor and delivery; 12. Infant nutrition: breastfeeding vs. bottlefeeding; 13. Preparation for bringing the infant home; 14. Description of and linkage with pediatric services. 15. Infant care, parenting skills, becoming a family; 16. Postpartum physical and emotional changes; 17. Family planning including preconceptual counseling; 18. A schedule of postpartum checkups; 19. A schedule of pediatric checkups; Using these topics as a basic outline, educational protocol should be developed for use by staff. Depending on the structure of the perinatal program, patient education can be the responsibility of the primary provider or can be shared among a variety of providers and other health professionals. In most programs, the responsibility is shared; the primary provider may cover all or most of the areas once with supplemental information given by ancther health professional, usually a nurse or a health educator who has special training in perinatal care. Larger programs find that it is useful and 32 cost-efficient to have a perinatal-trained health educator on staff to reduce the pressure on the medical staff to cover every topic in detail. Depending on their availability, health educators may see every perinatal patient at least once, either individually or in groups, or may see only those patients that the medical staff refer. A health educator can serve as the staff coordinator for patient education, taking responsibility for planning, organizing and scheduling individual and group education activities. The staff coordinator may conduct the educational sessions and/or provide training to other staff members to enhance their abilities to do effective patient education. The health educator’s skills should be used in assessing patient educations needs, identifying how to best reach the target audience for educational programs, developing or providing educational materials appropriate to the patient population and evaluating the effectiveness of patient education programs and materials. Patient education sessions that are held at different times than the medical visit often have a high no-show rate, particularly if the provider has not emphasized the importance of the visit. One approach is for a health educator or nurse counselor to be available for consultation during the perinatal clinic session on an "as necessary" basis. Another approach is to coordinate the schedules of the providers and the health educator so that appointments can be held sequentially. When scheduling patient education activities, programs also need to consider the schedules of their patients’ partners, who should be included in the sessions to the extent possible. An education checklist based on the program’s educational protocol is a useful tool for assuring that all topics are covered, and cne that is necessary if several different medical and educational staff members are responsible for providing patient education. An example of a comprehensive checklist is included as Figure V:A-1. The checklist should outline the topics that must be discussed during each trimester to provide an easy reference for what has and has not been covered. The perinatal staff person initials the section of the checklist as it is completed. The checklist remains in the perinatal record for ongoing reference by all members of the perinatal team. Perinatal patient education activities take many forms beyond one-on-one medical or counseling sessions. The following apprcaches can be used separately or in conjunction with each other to create a comprehensive health education program: Group classes, held at the time of the perinatal session or in the evenings. e Many programs have a program orientation/patient education session for all new perinatal patients. This is usually a one to two hour group session that introduces the patients to all aspects of the perinatal program: the number and timing of perinatal visits, the cost of the program and the services included in that cost, arrangements for delivery, basic 33 Billing Consult FIGURE [V:A-1 Educational Checklist Nutrition Consult Health Education Consult Records sent to Hospital Name Date Age G P ABS LMP EDC Hosy ital for Delivery verview of Care arnin S ‘agina eedin omina ain ema eadaches Su sturbances zz aintin emperature upture ° morares Decreased Movement Jtner, lnesses o anges Minor scomfres requent Urirnat Heartburn Nausea ackache Jyspnea Jaricose Veins Hemorrnoids ramps const ema ration schar at e reasts Increase ecretions rouble eepin e2din ums “Ligament Pain tretch Marks tion eta e Referr reastfee ass nancia ssues tamps kin reas oouches exu elations ntal Care Hea.un and Nutrition Issues. EA h + | - eck as discussed. -4 r ewoorn n. renat nemlia ca t. ain eta tatus eine rin ater nfant Nutrition nfant rep. Breast or ttle arent uipment/Car Seat ome reparations rep/Riv am elations Infant Care infant G rcumcision/npro&con Llrcumclsion are C ans/2wk-appt. utrition Lator an elivery ightenin Contract/False Labor 10 how,Mucus u upture o mbranes How to participate artner's Interest n sia/Anesthesia reathin elaxation ases o or Xpulsion ospit ostpartum xercise ues terpains reast Care yisiotom are am ann x Weeks eckup/appt. ne s. To ea andouts rocedqures Plan de :alud del Valle, Revised 2 34 nutrition, and basic growth and development of the fetus, and preterm birth prevention education. e Most programs also hold a series of four to six perinatal classes which cover the range of topics listed at the beginning of this section. Separate sessions should be designed for adolescents using appropriate educational material and addressing the specific interests and corcerns of this important group. Some centers have found that adolescents do not respond well to group sessions, preferring individual counseling. Since health and childbirth education is critical for this group, centers must remain sensitive to patient preferences and structure their educational program accordingly. Spouses, family members and important friends should be encouraged to attend individual or group educational sessions with both adults and adolescents to provide support. e A series of group classes is also commonly held which deals exclusively with preparation for childbirth, either Lamaze or some other technique. Depending on the demand for the classes and on the interests and skills of the perinatal staff, these classes are held at the health centers or patients are referred to another source. In all cases, childbirth education efforts should be closely coordinated with the delivery site so that both the perinatal patient and the delivery site staff will have similar expectations abcut how a delivery will proceed. Again, important support persons should be encouraged to attend these sessions. @ Other types of group education that can usefully be conducted by perinatal programs include: parenting skills, parertal support groups, exercise classes, and nutrition and cooking classes. Educational sessions may be most interesting to perinatal patients, their partners and other members of their support group if audio-visual aids are used and if a variety of health center personnel participate. This assures more consistency of presentation and reduces the amount of time that any one person needs to spend preparing for and conducting the classes. It is particularly important to include family planning and pediatric staff in these sessions so that all aspects of perinatal care are covered comprehensively during the prenatal period and so that perinatal patients have the opportunity to meet these members of the perinatal team prior to delivery. Audiovisual materials can also be shown in the waiting room during prenatal sessions. Vritten materials can play an important role in the patient education component of a perinatal program, depending on the composition of the patient population. Some programs have developed their own materials; others rely on materials that are available from other local groups, from local and state health departments and from state or nationsl programs. Several private companies and associations, many of which are listed in Appendix II, provide free or low cost educational materials, some of which 35 are excellent. It is important, however, when selecting materials for a CHC population that the material is carefully reviewed to assure it is culturally sensitive and appropriate and written for appropriate age and educational levels. Centers serving adolescents, non-English-speaking patients and new immigrants from different cultures must pay particular attention to the appropriateness of educational materials. Attendance is often quite low at group educational sessions, particularly when classes are held at night. One alternative is to hold the classes during the sessions when perinatal appointments are scheduled so that the patients only need to make one trip to the center. Patients should be allowed to leave and re-enter the classes as they are seen by the medical staff. Although this may be somewhat disruptive to the class, it clearly makes it easier for women to attend and more likely that they will attend. If possible, it is useful if the classes can be structured and sequenced so that a patient can, for example, attend and learn something from the third class in the series without having been to the second. With this type of structure, a patient who is unable to attend four or six weeks in a row may be able to attend each of the classes at some point during her pregnancy. Classes are.also more likely to be well attended if providers believe that they are useful, encourage their patients to attend, and follow up to see that they do attend. Another approach to encourage participation in educational sessions is to offer financial incentives for patients to attend; for example, new perinatal patients can be given five vouchers, each representing one session and worth $10 toward a reduction in the patient’s account if she attends the class. This type of system reinforces the idea that the information provided during the sessions is important and that an informed perinatal patient is a more efficient user of health center resources. B. Nutrition and Food Assistance (WIC) Because nutritional status is an important influence cn pregnancy outcome, it is necessary that nutrition assessment, education and services be provided for all pregnant women as in integral component of their perinatal health care. Women with different levels of risk require varying degrees of nutrition intervention by professionals with different qualifications and competencies. Optimal care requires the early identification of patients at risk for nutrition-related health problems and assurance that their subsequent care will include provision of the appropriate nutrition services. A nutrition plan/protocol should be developed to specify the nutrition services to be provided for all perinatal patients and to designate the member of the perinatal health care team responsible for each service. Nutrition services which sould be provided include: 1. Evaluation of current dietary practices. 2. Counseling on nutrient needs during pregnancy and dietary practices to meet these needs. 36 3. Education during the prenatal period on the advantages of breastfeeding and encouragement and instruction to initiate it and support during the postnatal period to continued breastfeeding or to manage alternate methods of infant feeding. 4. Counseling on nutrient needs during lactation and dietary practices to meet these needs. 5. Referral, as necessary, to community resources such as focd assistance programs (WIC, Food Stamps, or Commodity Supplemental Focd Program), educational programs in home management (Expanded Food ard Nutrition Program), etc. 6. Monitoring and interpretation of clinical data such as weight (plotted on a prenatal weight grid), hemoglobin level, blood pressure, urine protein, etc. 7. Identification of maternal risk factors. (See Figure IV-BE:1.) 8. Consultation with or referral to a registered dietician/nutritionist for those patients deemed at risk and who need specialized nutrition counseling. 9. Evaluation and management of patients at high risk at the onset of pregnancy or who develop nutrition-related problems during pregnancy. 10. Monitoring on a continuous basis those high risk patients receiving special nutrition interventions. In uncomplicated pregnancies nutritional needs are reasonably well-defined, and most nutrition services can be provided by the primary health care provider or perinatal nurse. These health professionals can provide education and counseling related to nutritional needs and diet during pregnancy and lactation; use the medical history, physical examination and laboratory findings to identify nutrition risk factors at the onset and during the course of pregnancy; monitor nutrition status throughout pregnancy; and make referrals for specialized nutrition intervention and to community resources. Such services that primary health providers and perinatal nurses can provide are Nutrition Services 1 through 8 above. A health educator can share the education component of Nutrition Services 3 and 4 above. The social worker can assist with Nutrition Service 5. In order to provide these services, it is particularly important that health professionals be adequately prepared to do so. All members of the team need access to periodic in-service education to keep up-to-date with regard to nutrition krowledge and community nutrition resources. They also need access to a registered dietitian/nutritionist for consultation regarding planning, coordinating, and monitoring nutrition service delivery as well as patient care issues and for referral of high-risk patients. 37 FIGURE IV-B:1 MATERNAL RISK FACTORS Risk Factors at the Onset of Pregnancy: 1. 2. 3. 10. Adolescence: les than three years post menarche. Three or more pregnancies within two years. Past reproductive performance characterized by abortions, pregnancy complications, low birthweight infants, or perinatal loss. Economic deprivation. Unusual dietary practices. Heavy smoker (more than 20 cigarettes per day). Excessive alcohol intake (chronic use or binge drinking). Drug addiction. Chronic systemic diseases. Pre-pregnant weight below 85 percent or above 120 percent of standard weight for height. Risk factors during pregnancy: 1. Hemoglobin below 11lg/dl; or hematocrit below 33 percent. Inadequate weight gain (less than lkg/mo.) Excessive weight gain (3kg/mo.) possibly associated with fluid retention. Risk factors following pregnancy: 1. Taken from: Nutritional demands of lactation. Board, National Academy of Sciences, 1981. 38 Nutrition Services in Perinatal Care, Committee on Nutrition of the Mother and Preschool Child, Food and Nutrition Women at high risk require more specialized care, both ir evaluation of problems and in nutritional management (Nutrition Services 9 and 10). This requires the services of a registered dietitian with training at the graduate level in the nutritional care of high-risk pregnancies. This nutrition specialist could be employed as a staff nutritionist or secured through a contract with a health department, hospital, or dietitian in private practice. The registered dietitian/nutritionist’s primary roles are planning, standard setting, coordinating, evaluating, andd quality assurance of nutrition services; providing continuing in-service education and consultation to members of the health care team; and providing nutrition care services to women with nutrition-related risk factors. Because adequate nutritional status depends on an adequate diet, a CHC perinatal program should be closely linked with food assistance programs such as the Special Supplemental Food Program for Women, Infants and Children (WIC) or the Commodity Supplemental Food Program (CSFP). Many CHCs have the WIC progrm on site, and this has several advantages which improve services for qualified patients--referrals are facilitatted; information exchange between the WIC program and the CHC staff is enhanced; WIC program staff provide some of the nutrition education and counseling services for CHC patients participating in the WIC program; and staff may be shared between the CHC and the WIC program. If the CEC does not maintain WIC or CSFP on site, referrals to one of these important resources should be formalized and patients tracked through the referral process. CHC staff need to be informed of exactly what nutrition services are being provided to which patients through the WIC program. The CHC must see that perinatal patients who are not eligible for VIC also receive nutrition services. The nutrition efforts of both the CHC and the WIC programs should be coordinated to assure that all patients receive appropriate nutrition services and that the information provided is consistent. C. Social Work Services Social work services in a perinatal program can be carried out in various ways depending on the structure and size of the program. Ideally, services should be provided by a professional social worker cr by other social work staff under his/her direction. Referral by trained social workers or appropriate medical staff to community social agencies is a secondary option. The social work services in a perinatal program fall into two broad categories of assessment and intervention. They include: 1. Assessment of the patient to identify emotional and behavioral factors that may negatively affect pregnancy outcome (e.g., emotional instability, substance abuse, etc.) 2. Social assessment ot ascertain the quality of social support available to the patient during the pregnancy and post-partum period. 39 3. Economic assessment of the patient to identify her ability to provide a required level of nutrition and shelter during and after pregnancy. Upon completion of the assessment, social work intervention can take the following forms and should take into account and include the father and other support persons whenever possible: 1. Direct individual counseling. 2. Peer group counseling (especially helpful for pregnant adolescents). 3. Supportive counseling to develop or strengthen family supports. 4. Genetic counseling. 5. Exploration of caretaking options for the baby, e.g., remain in family structure with mother and/or father, foster home placement, adoption. 6. Assist in obtaining services such as Medicaid and other financial assistance, nutrition service, transportation, day care and family planning. In addition, a qualified social worker should assist the medical staff in developing outreach services to ethnic groups whose perception of health and particularly pregnancy, may prevent the effective utilization of prenatal services. Social workers should work with leaders of ethnic communities to identify the cultural barriers that prevent pregnant women form seeking prenatal care and to develop specific outreach programs to overcome these impediments. Social workers should be skilled in individual family assessment and counseling, case management, community networking and client advocacy. They must be familiar with community resources, know eligibility requirements, and be able to develop working relationships with other community agencies. This information, in relation to individval patients, should be maintained in the medical record so it is accessible to other staff members. Social work staff will need to have time built into their schedules to network with other health and social service agencies and market the community health center in the community. These outreach activities can also provide a source of patients for the perinatal program. Once the area resources have been identified and a working relationship established between the perinatal program and other agencies, the social service personnel are responsible for assessing the individual perinatal patient’s need for services, providing the services cr making the necessary referrals, and following up to make sure that the problem or concern has been resolved. Depending on the resources available to the perinatal program, social service staff may routinely see every perinatal 40 patient for an initial assessment or may see only those patierts referred by the medical staff. Effective referral tracking is important. External referral tracking systems are discussed in Section V:C. D. Home Follow-Up Depending on the size of the programs, the characteristics of its patient population, and the skills of the home care staff, home care services can be carried out by outreach workers, nurses, nurse practitioners, and physician assistants, or through an outside agency such as a visiting nurses’ association or a local health department's public health nurses. In some settings and for some cases, physician staff may also be involved. In a CHC perinatal program, there are four tasic reasons for home visits: 1. To follow up on patients who have not kept their appcintments to determine the reasons and to provide necessary assistance; 2. To assess follow-through on a clinical recommendation; 3. To assess a patient’s home situation to determine its impact on her pregnancy and parenting and to suggest possible resources in the community; and, 4. To provide postpartum and infant care and support during the first weeks after delivery. This may be particularly important for women and babies who are discharged early from the hospital or birthing center, or who are considered high-risk for health or social reasons. If home services are provided by individuals who are not part of the perinatal team, the services will function as a referral rescurce. Home care personnel will not initiate visits, but will respond, for example, to the requests of perinatal administrative staff members who have determined that the patient is not keeping her appointments and is not responding to the standard approaches, to the requests of medical or educational perinatal staff that an assessment be made of the patient’s home situation, or to the notification by perinatal medical staff that a patient has delivered and is in need of a home visit for postpartum care. Visiting Nurse Associations, for example, may be a particularly valuable source of home care services for perinatal patients and CHCs should develop working relationships with this important local resource. Whatever source(s) of services is used, the individuals or agencies providing these home health services must be closely linked to the rest of the perinatal staff through carefully monitored referral systems. Another common approach is for perinatal staff members to perform home care services. For example, an MSV may be responsible for any home visits that are not medically related. A nurse, nurse practitioner, physician assistant or certified nurse midwife may be responsible for visiting the mother and baby at home after delivery. The purpose of this visit is to 41 examine both the mother and the baby, to provide emotional support to the family, to assess infant care and parenting skills, and to determine the need for additional medical and social services. This visit also provides an opportunity to remind the family about the continuing need for clinic visits and to schedule the visits if this has not already been done. Home care services are generally expensive because of the large amount of staff time or referral resources that they require. Many programs find that it is not feasible to provide the services except in emergency situations, when early discharge is commonly practiced, or in cases where either the mother or baby is considered high-risk. As part of their standard protocol, programs should identify categories of patients to receive scarce home health resources. E. Outreach and Marketing Marketing, broadly defined, involves designing, implementing, and promoting a perinatal care program that is attractive to and meets the needs and demands of the target population. Outreach refers to the actual activities related to informing potential patients about the services, describing how the services can meet their needs, and encouraging patients to seek care when needed. Perinatal marketing and outreach programs in CHCs should be viewed primarily from the perspective of promoting early and appropriate use of perinatal care services to improve the haalsh of mothers and babies. Secondarily, marketing and outreach may be used to increase utilization of perinatal services in new or growing programs. Typically, hcwever, CHCs which offer high quality perinatal services find their service is much in demand. Educating patients for early and appropriate use, however, is more of a challenge. Further, potentially high-risk patients, e.g. adolescents, patients of lower socioeconomic levels or patients of different culture may be the most difficult to bring into the program early and keep in on an appropriate basis. Marketing and outreach activities can be directed at three audiences: 1. Women who are users of the CHCs perinatal services; 2. Women who are already health center users but have nct used the perinatal services; and, 3. Women who have never used the health center’s services. The first audience, current perinatal patients, is the easiest to reach and maintain because it is a captive audience; if a patient does not keep her appointments, the staff has ready access to her address and to information about her health, education and social service needs. The key here is to establish information and tracking on patients as early as possible, preferably at the time of an initial counseling session conducted in conjunction with a pregnancy test. Marketing and outreach activities for existing patients should be directed at encouraging better use of the perinatal services including: making and keeping appointments for medical, 42 educational, and social services; attending group classes; ard, following the nutrition and health education advice received. Marketing and outreach tools to use for this group include: active implementation of the tracking and referral systems discussed in Section V; a personalized, extensive orientation to the program; written and visual educational raterials in the waiting and exam rooms; patient satisfaction questionnaires; and, of course, personalized, friendly, high quality care by the perinstal staff. The second audience includes women who use the health center’s other services but are not current users of the health center’s perinatal services, either because they are not pregnant or because they have chosen to use other providers for their perinatal services. Outreach activities for this group should be designed to encourage women to seek early care, informing them about the scope of the perinatal program, and introducing them to the qualifications of the perinatal staff. Marketing and outreach tools include: written, visual and audiovisual materials dealing both with perinatal care in general and with the health center’s perinatal program in particular; mailings to the entire patient population describing the perinatal program; mailings to patients identified by CHC staff as being at high-risk for becoming pregnant or for having high-risk pregnancies; and strengthening the linkages between the perinatal program and other parts of the health center, particularly the pediatric and adolescent programs. One approach is to prepare a pamphlet which describes the various aspects of the perinatal program and includes a picture and qualifications statement for each member of the perinatal staff. Another is to have perinatal pamphlets and posters in the general waiting rooms. A third approach is to provide free pregnancy tests on a walk-in ltasis during health center hours with referrals to a provider, as appropriate. Programs can also increase the number of perinatal patients and improve early entry into care by arranging to perform all pregnancy tests in the perinatal unit or by having family planning or general medicine staff automatically and formally refer all women with positive pregnancy tests to the ps program. By formalizing the referral process, these women become part of the recall and tracking system from their initial contact with the CHC and are contacted if they do not make or keep their appointments. Many CHCs will concentrate their marketing and outreach activities on these first two groups of patients. Because of the high cost of providing perinatal care, programs find that they are functioning at capacity without going beyond the population they already serve. Outreach beyond the already existing patient population makes little sense if it creates expectations that the program cannot meet; the net effect of an external outreach program can be negative if the program does not have the resources to meet the demand that is created. The third audience includes women who are not patients of the health center because they have not heard of the center and its prcgrams, they have never had a need for services, they have another provider whom they are satisfied with, or they have a negative impression of the health center and its staff. If a perinatal program can handle additional patients beyond the health center’s existing patient population, it will first want 43 to target specific, possibly high-risk groups that have beer identified through the needs/demand process. Different approaches will te successful with different target populations. The following approaches have been successful in bringing patients into CHC perinatal programs: eo Developing formal and informal linkages with other health, social service, and welfare agencies in the community; e Providing health, educational, and counseling services within the schools, preschools, day care centers, head start programs, and churches to discuss the necessity of early prenatal care, and the availability of services at the CHC; eo Forming and promoting a speaker’s bureau, composed cf perinatal staff members who are available to speak to community and other groups and to the media about issues related to perinatal care; e Targeting particular neighborhoods or apartment buildings for canvassing or leafletting; eo Writing a column in a local paper or participating in a local radio show dealing with perinatal-related issues; and e Collaborating with free-standing or solo family planning providers. Marketing and outreach encompass a variety of activities which can be planned and carried out by different people within the community health center. Many of the activities are carried out as part of high quality, responsive care whether or not the program is formally pursuing a marketing strategy and whether or not the activities are even thought of as "outreach." Designing and monitoring an overall marketing approach should be the responsibility of an individual or a team that has the perspective to know how the perinatal program fits into the CHC’s larger programmatic goals and into the community’s perinatal system. F. Transportation In some settings, particularly rural areas, lack of transportation may be one of the most important barriers to receiving ongoing perinatal care. Unfortunately, with funding cuts and increased medical costs, transportation services are often reduced or eliminated. With creative scheduling techniques and with the assistance of volunteers, some programs have been successful at keeping some level of transportation services. One approach is to organize a network of volunteers, through a local civic group, who are available to provide transportation to patients. Even in the best of situations, it is difficult to schedule the transportation and the clinic visits so that the patient does not have to spend all day receiving perinatal care. It is often unrealistic for a 44 program with some transportation services available to plan more than one round trip per day into a particular area or even more than one per week. As with any internal or external referral service, perinatal staff members who are responsible for arranging transportation for patients need to work closely with the transportation manager. For example, it may be more efficient to reserve certain blocks of appointments for only patients requiring transportation. Knowing that these blocks are available may improve the transportation department’s ability to plan and may, therefore, reduce the amount of time the patient using transportation spends waiting and may increase the number of patients who will benefit from the transportation services. 45 Vv. SYSTEMS SUPPORTING A PERINATAL PROGRAM The following sections discuss the administrative systems that should be in place in a smoothly functioning perinatal care program. While the emphasis is on the components of systems that are unique to a perinatal program, more generic issues are also discussed. Major objectives for each system are listed, the potential components of each system are described, and examples of systems are presented. The systems that will work best in a given situation will be based on a number of factors including the size of the CHC and the perinatal patient population, the model of care, the availability of support staff, the resources available to patient population, and the size of service area; systems should be adapted to each center’s special characteristics and resource constraints. In addition, systems do not work independently of each other. Fcr example, a good patient tracking and recall system depends on a smoothly functioning appointment system. A comprehensive quality assurance program must include an effective tracking and recall system. It is still wcrthvhile to implement or upgrade a component if the entire system cannot be changed, but it is important to recognize how weaknesses in one part can reduce the effectiveness of other parts. A final point: well-designed systems are meaningless if they are not well-implemented, monitored and altered in response to changes in the program. It is important to have a mid- to senior-level staff member responsible for overseeing these systems to assure that they are functioning smoothly, that all of the tasks are actually being carried out and that information being gathered as a result of the systems is being used for programmatic decision-making. A. Appointment Systems A perinatal scheduling system should be designed and implemented to meet the following basic objectives: ° Providers are ready to see patients when patients are ready to see providers, and vice versa. ° Vaiting time is kept to a minimum so that patients are not inconvenienced and discouraged from keeping future appointments. ° Sessions with other perinatal services staff can be scheduled in conjunction with medical appointments. ° New patients can be seen promptly (within a week) and returning patients can be seen at times that are ccnvenient for them. ° Appointment-keeping is encouraged and patients who miss appointments are easily identified. 47 To design a new appointment system for a perinatal prcgram or to evaluate an existing system, the following questions need to be considered: 1. Should a separate block of time be set aside fcr perinatal appointments or should perinatal appointments be integrated into the providers’ general schedules? Having a separate block of tire available for Serinatal visits has the advantage of focusing the attention of the providers and support staff on the special needs of perinatal patients. For example, informal group education can be provided to perinatal patients in the waiting room, or audio-visual and/or written materials can be available. The nutritionist, health educator and/or social wcrker can be scheduled to see perinatal patients during the specific hours; and outside resources, such as WIC, childbirth educators, or hospital personnel can be brought in during this period to meet with patients individually or in groups. Some CHCs, particularly those with large perinatal patient populations, have found it advantageous to have separate sessions for particular subgroups such as high-risk patients and teenagers. Special sessions for high-risk patients are particularly useful if OB/GYNs are available on a limited basis and if resources are available to provide classes to groups of high-risk patients. Tracking and recall systems may also be more efficiently used if all high-risk patients are rcutinely seen during the same session. Special teen sessions and separate teen clinics, which are designed to meet the special needs of pregnant adolescents, have been effective at a number of CHCs. Sessions are scheduled in conjunction with area schools at times that are convenient for teens. Often more time is allocated for appointments and a greater emphasis is placed on education and counseling. When a separate location is also used, the atmosphere can be designed for teenage tastes. 2. Will patients be given individual appointments or be assigned to a particular block of time Sor example, 9-11 a.m.) with patients being seen on a first come, first served basis? Individual appointments are almost always preferred because waiting time is reduced for individuazl patients, they are more satisfied with the services, and are more likely to return for subsequent appointments. However, block scheduling may te necessary when a large group of patients arrive at the same time because they use transportation provided by the health center. Health centers forced into block scheduling should be sure that waiting time is not wasted. For example, education, nutrition and parenting activities can te scheduled during the waiting time. 3. How many perinatal visits are necessary? At a minimum, CHCs should follow the American College of Obstetricians and Cynecologists (ACOG) standards in scheduling perinatal patients: one visit per month for the first 28 weeks, every two to three weeks until the 36th week gestation, and every week thereafter. In addition, a postpartum visit should be held four to, at most, six weeks following delivery. Infants should be seen at two weeks and six weeks and infants discharged within 24 hours also need a 48 hour follow-up visit. 48 Additional medical visits will be necessary for high-risk patients or for patients with special needs. This judgement can only be made through the use of ongoing risk assessment. For example, women at high risk for preterm birth will need to be seen every week from 22 weeks gestation. The amount of time allocated for medical visits will depend on a range of factors including the types of providers that will be involved, the availability of auxiliary and other staff, and the shifting of orientation and education functions away from the physician, certified nurse midwife, nurse practitioner or physician assistant. Typically, 30 minutes are allocated for the medical portion of the initial prenatal visit and 10-20 minutes for each additional visit with more time made available if the medical visit will include education. In addition to medical visits and depending on the scope of a particular program and the availability of appropriate staff, the following components of comprehensive perinatal care should also be provided, with time allocated in the scheduling system: 1) Orientation to the perinatal program. Parts of this orientation can be held in groups, others must be on an individual basis. This visit would normally be provided by a nurse and may include having the patient complete an initial medical history, arranging for basic lab tests and providing information in the following areas: services provided by the perinatal staff, cost of services, patient rights and responsibilities, options for delivery sites, availatility of educational resources, basic nutrition, basic fetal developmental and danger signs. Usually, two hcurs are allocated for this visit. Often the orientation is scheduled one week before the first visit with the physician, certified nurse midwife, nurse practitioner, or physician assistant so that the history and the lab results can be available at that time. 2) Ongoing educational visits with a perinatal nurse. These visits are generally held on an individual basis and immediately before or after the medical visit to assure that the patient receives ongoing information to reinforce what the physician, certified nurse midwife, nurse practitioner or physician assistant has told her at previous visits cr at the current visit. 3) Individual sessions with a staff nutritionist, health educator, and/or medical social worker. These visits can be provided either to all patients or to high-risk patients. Initial sessions with these professionals are generally scheduled for one hour; follow-up visits may be scheduled for 30 minutes. 4) Individual or group educational sessions on nutrition, preparation for childbirth, parenting skills, family planning, orientation to pediatric services and. orientation to hospital services. These sessions can be held during the prenatal session with patients attending before and/or after 49 the scheduled medical appointments or in the evenings. The length of time spent can vary significantly dependirg on the amount of information covered. CHCs generally provide a series of four to six classes, each lasting one to two hours. Ideally, the range of visits necessary for comprehensive perinatal care can be coordinated to minimize the number of visits that ratients must make to the clinic. For example, it is often helpful if a medical visit can be coordinated with a visit to the nutritionist or if classes can be scheduled to coincide with the prenatal session. As mentioned above, one approach is to have the nutritionist or health educator available during the hours of the session so that same day referrals can be made. Another is to have the perinatal appointment clerk control the nutritionist or health educator’s schedule during those sessions so that the two appointments can be scheduled for the same session. The perinatal team should meet regularly to review cases and "failures" (such as neonatal deaths, low birthweight babies, etc), assess progress, discuss problems, and assign responsibility for follow-up. At a minimum, the various appointments and their results should be recorded on the medical record so that each member.of the perinatal team is aware of what the other is doing (see section V.D.). 4, How should the initial series of prenatal visits be scheduled? In most CHCs, perinatal patients have three basic initial contacts with the perinatal program: the pregnancy test, the initial prenatal/orientation visit, and the initial physical exam. The first two visits are usually provided by a nurse and the third by the physician, certified nurse-midwife, nurse practitioner, or physician assistant. Since these visits are usually held sequentially, it is important that tke amount of time between appointments be kept to a minimum. This can be achieved, in part, by keeping specific slots in the schedule open for the orientation visit with the nurse and the prenatal exam with the physician, certified nurse midwife, nurse practitioner or physician assistant. If the slots are not used for this purpose they can be filled by walk-in patients. The orientation visit should be scheduled within a week of the results of the pregnancy test and the physical exam should be scheduled as socn as the lab results are available. The goal, of course, is to completely enroll women in the system as early as possible. In some centers the pregnancy test visit is treated as the first prenatal visit: a history is taken, lab work is initiated, and preliminary counseling and education take place. This approach has the zdvantage of tying the woman into the system early. In general, though, this type of arrangement is difficult in a busy center because pregnancy tests are often requested on short notice, frequently on a walk-in basis. It also may not be cost-effective in centers where a significant proportion of women do not continue their pregnancies, although it is important that these women be followed up for family planning services. If it is not practical to initiate care at the time of the pregnancy test, centers should strive to counsel patients and schedule the initial visit immediately. Patients can 50 then be entered into the center’s tracking system and those patients who miss their initial appointment can be immediately contacted. 5. How should the appointment book be formatted? The actual appointment book can take many forms, depending on the decisicns that have been made about the issues raised in the above sections. Generally, though, each provider should have his or her own page in the appointment book and space should be available to record the following infcrmation: Patient's name Patient’s chart # Patient’s telephone # Patient kept appointment (yes, no) Type of visit (pregnancy test, orientation, initial physical, medical revisit, educational revisit, etc.) eo Follow-up performed (rescheduled, phone call, home visit, etc.) 6. How can missed appointments be avoided? With many patient populations, a smoothly functioning clinic session results in low no-show rates: patients learn that if they arrive on time they will be seen on time. In most centers, however, three basic types of activities are necessary to assure that appointments are kept: patient education about the importance of keeping appointments; systems for reminding patients that they have appointments; and, follow-up of patients who miss appointments. Health centers that have low no-show rates often include, as a formal part of their prenatal patient orientation session, a discussion of the importance of keeping each appointment. If a center charges a "package price" for perinatal services, it may be useful to point out to patients that they are wasting money if they do not fully use the services. As with any type of primary care visit, patients are more likely to attend if they are reminded about the appointment beforehand. This can be done with a postcard or telephone call. Telephone calls are preferable and are essential for high-risk patients or patients missing more than one appointment. Home visits should also be used if necessary fcr high-risk patients or patients who habitually miss appointments. At a minimum, a mailed reminder should be sent to low-risk patients missing a prenatal appointment. Tracking and following up on missed perinatal appointments may be done as part of or separately from the health center’s regular appointment recall system. It may be done through a card file system where cards are moved by week of appointment; it may be done in a lcg book where every appointment is noted; or it may be done by checking the charts of all no-shows at the end of a session. The point is that some flag must be raised if a patient does not keep a scheduled appointment. B. Patient Tracking An effective patient tracking system for a perinatal care program is designed to meet the following objectives: 51 ® To assure that high-risk women and infants are easily identified so that their care can be more accurately monitored. ° To assure that perinatal patients attend all necessary medical and educational visits, based on their estimated delivery dates and that infants are brought in for all necessary services. ° To assure that all critical administrative tasks are carried out for each perinatal patient. These tasks include serding a copy of the the patient’s medical record to the hospital. ® To provide information on pregnancy outcomes. The tracking system may be composed of many parts: an appointment reminder system, a card file or patient log system which lists critical steps in the perinatal care process and tracks patient visits, and a system for flagging high-risk patients. This section provides some suggestions for what information should be collected for patient tracking and for maintaining the information. Each health center, however, should review its own systems to assure that needed data is collected but not duplicated. 1. Appointment system. As mentioned in the previous section, an appointment/scheduling system is integrally tied in with a patient tracking and recall system. A good appointment system will easily identify women who have missed their appointments and will include a mechanism for contacting these women and setting up new appointments. An appointment system will not, however, identify women who did not make an appointment in the first place. Without a good tracking system, it is likely that some women will "fall through the cracks." This includes women who initiate prenatal care but do not continue to make and keep additional appointments, women who do not continue their pregnancies and need family planning services, patients who do not schedule the nonmedical appointments that are an important part of prenatal care, and women who do rot schedule postpartum and well baby visits. 2. Patient log. All health centers should maintain a log on all their perinatal and newborn patients. The log may be in a bock, card file or computer. Women’s records may be filed in a variety of ways but the most useful is by expected delivery date as many of the activities in the perinatal cycle are tied to this. The basic types of logs are discussed below. These can te altered in a variety of ways to meet the needs of particular programs. Computerized systems are not discussed, although the same principles would apply in their design. The perinatal log can include a variety of information depending on the amount of time available to the staff for filling it out, the availability of staff to follow up on information that is gathered in the 52 log, the likelihood that staff will use the information for programmatic decision-making, and the availability of other sources for the data. For purposes of patient tracking and recall, the following information, at a minimum, is needed: 1. Patient’s name 2. Patient’s chart number 3. Last menstrual period and/or estimated date of confinement (EDC) 4, Enrollment date 5. Date of each perinatal visit (whether the appointmert was kept and follow-up action taken). 6. Primary provider 7. Age of patient 8. High-risk 9. Hospital 10. Date(s) medical records sent to hospital 11. Actual delivery date 12. Date delivery summary received 13. Pregnancy outcome 14. Postpartum exam(s) (Yes/No, Date) 15. Enrolled in system for family planning and gynecological services (Yes/No, Date) 16. Enrolled in system for well baby care (Yes/No, Date) 17. Well baby exam(s) (Yes/No, Date) An example of a perinatal log, where information is kept in a book, is included as Figure V:B-I. A prenatal log can also be kept ty using an index card rather than a notebook file. One index card is kept for each patient and the cards are filed according to the patient’s ELC and then alphabetically. The same type of information can be kept using this system and could be included in the notebook format. An advantage of this type of system is that more information can be kept in a less unwieldly form. Also, the cards of women whose EDCs change can be shifted to the appropriate category more easily, and cards can be reactivated for future pregnancies. The following additional information would also be useful for programmatic analysis and decision-making, if sufficient tracking and recall resources are available. 1. Payment source 2. Breastfeeding (Y/N) 3. APGAR score 4. Veek of gestation at entry into program 5. Hospital orientation (Y/N); Date 6. Referred to WIC/enrolled in WIC (Y/N) 7. Other referrals made (list to whom) 8. Results of referrals received (Y/N) 9. Patient’s address and/or telephone number or some other means of contact 10. Marital status 11. Number of children 53 FIGURE V: B-1 Month and Year EDC: Medical Delivery Vell-Baby High Risk preterm Birth Enrollment Visit Primary Records Delivery Summary Pregnancy Postpartum Exams Name Chart { (Y/N) Score A EDC D _ Dates Provider Hospital _ Semt Date /n Out come Exams (Dates) 3 ~ ~~ wy Summary Data: Age at Entry Trimester of Fntry lst 2nd 3rd Under 18: 18 and Over: 12. Consultation with nutritionist/ MSW/health educator (Y/N) 13. Lab work complete (Y/N) 14. Infant status at birth Special logs can also be kept to monitor specific components of the perinatal program or specific subsections of the perinatal patient population. For example, a separate log can be kept for high-risk and/or teenaged patients, and information could be recorded which is unique to these groups. Referrals can also be tracked and followed up on by use of a log (see Section V: C,D). Tracking systems are most effective when one staff member, usually a nurse, is responsible for maintaining the log. Patients should be logged in as soon as possible, preferably following the pregnancy test and counseling session. Thereafter, additional information should be added as soon as it is available. At the end of each session, the nurse should review each chart and record any relevant information on the log; at a minimum the date of the visit and any change in risk status should be noted. On a regular basis, optimally every week but certainly every month, the logs should be reviewed and the following basic questions asked: 1. Which patients (with particular attention to high-risk patients) have not been coming in as often as appropriate (using the data on LMP, EDC or gestation at entry into the program together with the protocol for spacing and frequency of visits, and comparing this to the actual dates of visits)? 2. Have hospitalization arrangements been made? 3. If appropriate, have the medical records been sent to the hospital? 4, For patients who have delivered (or should have delivered), has the appropriate documentation been received from the hospital and have medical visits been scheduled for the mother and baby? And, depending on the additional information that has been collected, the reviewer should also ask if various appointments and referrals have been made and kept (hospital orientation, well-baby, postpartum, WIC, nutrition, social work, other outside consultants, etc). The nurse or other staff person with responsibility for keeping and monitoring the log should also be responsible for assigning the task of following up on the unsatisfactory responses to the questions. Just as a program should not spend resources collecting information that it will never look at, it also should not bother asking questions if it cannot follow up on the answers. Tracking and recall of patients, nc matter how well-designed the system, is a time consuming, labor-intensive process. It is better to design a system that can, realistically be implemented than to spend resources collecting data that will not be used. 35 2. Medical records forms. As well as providing clinical information, medical Tecords forms can be used to track the progress of prenatal patients. Checklists can be designed for a variety of purposes, including: 1. Making sure that basic administrative tasks are performed for each patient; 2. Making sure that particular medical and educational services are provided for each patient; and, 3. Assuring that the results of internal and external referrals are received. As appropriate, these checklists are discussed in other sections of the manual. Other examples of appropriate checklists include a simple. checklist on the outside of each patient’s medical record which contains some of the same basic tracking information as the prenatal log. A more extensive checklist can be kept as part of the medical record itself and used to keep track of the specific areas of education that have or have not been received. This type of checklist is most effectively used to monitor the care that an individual is receiving rather than to quickly monitor the care that the entire universe of perinatal patients is receiving. However, medical record checklists can be effectively used for periodic chart reviews of all patients. It is important to carefully think through the entire tracking system so that effort is not wasted or information duplicated. For example, unless the program administrator feels that cross-checks are needed, there is little reason to track whether a patient is receiving the appropriate number of visits on both the medical record and the patient log. Cc. External Referral Tracking Referrals outside of the program can happen fairly routinely or rarely, depending on the model of perinatal care being used ty a health center, the needs of the patient population, and the availability and organization of services in the community. Large, multi-disciplinary programs which have in-house specialists and capabilities fcr providing nutrition, health education, and social work services are likely to make outside referrals only on a limited basis. Programs which are staffed by family practitioners and/or certified nurse midwives, nurse practitioners or physician’s assistants, and programs without nutritionists, health educators or social workers may also need to make a significant number of referrals for high-risk and special needs patients. Some referrals will be for one consultation, others for ongoing care. An external referral tracking system should be designed to meet the following objectives: @ To assure that patients who need referrals outside of the CHC actually make and keep their referral appointments; and, 56 ® To assure that the results of the referral are reported back to the primary provider at the health center. There are two basic components of an external tracking system: a referral form that is sent to the consulting provider and agency; and a referral log or other mechanism for monitoring the status of each referral. A typical referral form is shown as Figure V:C-1. A form should include space for: the date of the referral, the patient’s neme, address, telephone number, and medical record number; the name of the primary provider, and the CHC’s name and address; a description of problem, including a brief history; an indication of whether the referral is for one time or ongoing consultation, a reply by the consulting provider, including recommendations for treatment and/or follow-up; the signature of the referring provider; and the name of the health center staff member responsible for monitoring the paper flow. Forms should be in triplicate: the original should be sent to the referring provider to return to the health center at the end of the consultation; one copy should be placed in the patient's medical record; and, the third copy should be kept by the health center staff person responsible for monitoring external referrals. A fourth copy can also be included for the consultanting provider or agency. Some programs, particularly those with a minimal number cf referrals, find that they are able to maintain control over the referrals by keeping all of the forms in a folder and making one individual responsible for periodically reviewing them and determining if follow-up is necessary. This approach is definitely preferable to each provider doing the paperwork for his or her own patient’s referrals and being responsible for following up to assure that the referrals take place and the paperwork is returned to the health center. Larger programs or programs with a large volume of referrals may find that follow-up is less time consuming and more effective if a referral log is maintained. The following information should be included on the log: Patient’s name Patient’s address and/or phone number Patient’s chart number Name of provider making referral Name of consulting provider or agency Consultant provider’s telephone number Date of referral request . Date of appointment Date referral results received 10. One-time or ongoing consultation 11. Reason for referral 12. Source of payment vo Uns WwNE A referral should be logged in as soon as the request is sent to the consulting provider. If the health center staff is assisting the patient with scheduling the appointment, the appointment date should be noted on the log. Periodically, preferably once a week, the log should be reviewed 57 FIGURE V:C-1 REFERRAL FORM Community Health Center Patient” s Name: Patient’s Chart #: Address: Phone: Payment Source: Health Center Contact Person: Phone: Health Center Referring Provider: Diagnosis/Condition: Phone: ——————————————————————————— Services Requested: Referred to: Phone: Address: Date of Referral: Date of Appointment: Evaluation: Follow-up Required: Dates Results Received: 58 Referring Provider’s Signature Date and any follow-up action taken. Knowing the appointment date will help the staff person determine when the results of the referral should reasonably be received. If the appointment date is not known and cannot be obtained from the patient, criteria should be set for when to follow-up, based on the date the referral was made. Follow-up to the consulting provider can be done by telephone or by standardized letter, either by the referring provider or the staff member responsible for monitoring the external referral tracking system. As with any administrative system, however, it is important that one person be primarily responsible for its implementation. It is helpful for the responsible health center staff member to meet with consultants who are frequently used for referrals to set up a referral system that is mutually acceptable. D. Internal Referral Tracking The major purpose of an internal referral tracking system is to make sure that perinatal patients see the health center staff and receive health center services that the primary provider determines they reed. These could include other physicians, the nutritionist, the health educator, the social worker, the psychologist, and/or lab. A perinatal program with a small staff will have limited use for a formalized internal referral tracking system beyond the other systems already in place. Many programs successfully use the medical record as the main vehicle for communication between perinatal staff and cther health center staff. In addition to its other uses, a perinatal log (see Section V:B) can be used to determine whether patients have seen tke auxiliary staff that perinatal patients routinely see. Space can also be left on the log to note any other health center providers that need to see particular patients on a special case basis. Checklists, as discussed in Section V:F, are useful not only as guides to the medical, administrative and educational services that need to be provided during the periratal period, but also to help the primary provider determine if additional services need to be provided by health center staff. Larger programs or programs with widely dispersed staff can often benefit from formalizing the internal referral process. At a minimum, a program may want to formalize the tracking system for high-risk patients. The basic approach is the same as for an external referral tracking system: duplicate referral forms (one copy in the medical record, one copy to the health center staff person handling the referral, and one ccpy for the file); and, possibly, referral logs. One staff person should be responsible for maintaining the system and providing the follow-up. E. Perinatal Medical Records Systems A separate section of the medical record should be devoted exclusively to the perinatal period. While a large or specialty-based program with its own administrative staff may find it more efficient to maintain its own set of medical records for the perinatal period, it is almost always preferable to maintain one medical record for all aspects of health services. Some 59 health centers compromise by storing a woman’s general medical record in the perinatal clinic during her perinatal period. A new, separate record should be created for the baby. The basic components of a perinatal medical record include: 1. A registration form which includes financial and administrative information. (This is often the same form that is used in the general medical clinic); 2. Problem list (again, a generic problem list can be used); 3. A physical exam form. 4. A prenatal history form which, in addition to general information on the woman’s medical history, also includes a history of previous pregnancies, the current pregnancy, and a risk factor assessment; 5. Lab, x-ray and other test results; 6. A perinatal flow sheet showing the basic findings of each perinatal visit; 7. Progress notes; 8. Referral forms, including the findings from any referrals; 9. Nutrition and health education checklists; and 10. Hospital discharge summary. Some of these forms are already used for other CHC patients and can be used in the perinatal record with little or no change. Other components can be combined on one form. There is no need to "reinvent the wheel" when designing perinatal records. Programs should contact state and local health departments and local hospitals and professional societies to see what is commonly used in the area so that regional networking can be facilitated. Perinatal records that are commonly used in CHC programs includes PROPAS (Problem Oriented Perinatal Risk Assessment System) and the Hollister perinatal system. Providers should, of course, be involved in choosing or designing a perinatal record, and the record should be acceptable to the hospital(s) where deliveries will take place. It will do little good to have well-designed forms if providers feel uncomfortable using them. More important than the actual design of the medical record and its individual format, is that all of its components be consistently used. This is particularly critical in a setting where the same provider is not performing all of the prenatal care, delivery, and postpartum care. Any provider should be able to pick up the record and quickly determine the patient’s risk status and pregnancy history. The risk assessment section of the perinatal record is an important tool that should be used throughout the prenatal period. The form should 60 be used both to determine any pre-existing risk factors and to monitor risk factors that might develop during the pregnancy. Risking tools should be tied directly to the program’s medical protocol and should te used, in part, to determine the type of provider that should be treating the patient. An initial risk guide can take two different forms: 1) A list of risk factors, each of which is assigned poirts depending on the relative risk involved. These risk factors range from low socioeconomic status to previous difficult delivery to clkronic renal disease. The provider checks off the relevant risk factors, the total number of at-risk points is determined and, based on that score, the patient is classified as not at-risk, at moderate-risk, or at high-risk. Vith this system a woman with several low-scoring risk factors can be classified as high-risk. 2) Risk factors are divided into two or more sections. The first section includes moderate risk factors such as low educaticnal status, younger than 15, older than 35, or previous preeclampsia. The second section includes high-risk factors such as diabetes mellitus, drug addiction and prior fetal or neonatal deaths. One or more cf the risk factors in the first group indicates that the woman is at mcderate-risk; one or more factors in the second group indicates that the woman is at high-risk. Depending on how the risking list is designed and on the items included on the sheet, the same form can be used on an ongoing basis during the perinatal period. More commonly, the perinatal record should include a continuing risk guide which includes potential risk factcrs such as smoking, failure to gain weight, or inadequate pelvis, and high-risk factors such as hypertension, severe preeclampsia, and alcohol or drug abuse. An important resource for programs that are developing risk assessment tool or reviewing existing risk assessment tools is the 1985 Institute of Medicine Report entitled Preventing Low Birthweight. The report reviews the risk factor literature and, when possible, weights the various risk factors. Table V E-1, is taken from the report and summarized the various risk factors, dividing them into six major groups: risks related to demographic characteristics, medical risks that can be identified prior to conception, medical risks that develop during the pregnancy, behavioral and environmental risks, health care risks, and risks about which there is more disagreement. This categorization suggests that reducing risks requires intervention in a variety of ways, by wide range of health and social services personnel, at many points: preconception, prenatal, postpartum, intrapartum. Perinatal flow charts should include space to record tke following information for each visit: 1. date of visit 2. weight this visit and cumulative gain 3. blood pressure 4, urine (protein, sugar and ketones) 61 II. III. IV. TABLE V:E-1 Principle Risk Factors for Low Birthweight Demographic Risks A. B. Cc. D. E. Age (less than 17; over 34) Race (Black) Low socioeconomic status Unmarried Lov level of education Medical Risks Predating Pregnancy A. B. Cc. D. E. F. G. Parity (0 or more than 4) Low weight for height Genitourinary anomalies/surgery Selected diseases such as diabetes, chronic hypertension Nonimmune status for selected infections such as rubella Poor obstetric history, including previous low birthweight infant, multiple spontaneous abortions Maternal genetic factors (such as low maternal weight at own birth) - Medical Risks in Current Pregnancy A. B. Cc. D. E. F. G. H. I. J. K. Multiple pregnancy Poor weight gain Short interpregnancy interval Hypotension Hypertension/preeclampsia/toxemia Selected infections such as symptomatic bacteriuria, rubella, and cytomegalovirus First or second trimester bleeding Placental problems such as placenta previa, abruptio placentae Hyperemesis O0ligohydramnios/polyliydramnios Anemia/abnormal hemoglobin Isoimmunization Fetal anomalies Incompetent cervix Spontaneous premature rupture of membranes Behavioral and Environmental Risks A. B. Cc. Smoking Poor nutritional status Alcohol and other substance abuse (continued) 62 D. DES exposure and other toxic exposures, including occupational hazards E. High altitude Principal Risk Factors for Low Birthweight V. Health Care Risks A. Absent or inadequate prenatal care B. Iatrogenic prematurity VI. Evolving Concepts of Risk A. Stress, physical and psychosocial B. Uterine irritability C. Events triggering uterine contractions D. Cervical changes detected before onset of labor E. Selected infections such as mycoplasma and Chlamydia trachomatis F. Inadequate plasma volume expansion G. Progesterone deficiency Taken from Preventing Low Birthweight, Committee tc Study the Prevention of Low Birthweight; Division of Health Promotion and Disease Prevention; Institute of Medicine. National Academy Press: Washington, DC, 1985. 63 5. estimated weeks gestation (by date and palpation) 6. edema 7. HCT 8. fundal height 9. fetal heart rate 10. estimated fetal weight 11. fetal activity 12. presentation 13. date of next appointment 14. risk status Space should be left for short notes at each visit with a reference to the appropriate page of the progress notes for more detailed information. Administrative and educational checklists are also an important part of the perinatal record. If consistently used, these checklists (which are discussed more fully in Section V:B) will identify the administrative tasks that have been carried out and the areas of nutrition and health education that have been covered. Examples of these checklists are included in Section V:B. . CHCs which serve a large migrant or transient population should consider using a travelling medical record for this group. One option is to provide the woman with a copy of her record which she can carry with her to her next location. Another is to use a specially designed migrant portable OB/Prenatal Record, one of which is distributed by Plan de Salud del Valle in Ft. Lupton, Colorado. This is a compact record, printed on heavy stock, which is folded and put into a plastic envelope. Depending on the length of time the woman will be in the area, this record can be used as the only medical record (with a copy kept on file at the health center) or in addition to the program’s regular medical record. F. Quality Assurance Broadly defined, a quality assurance program for perinatal services should be designed to meet the following objectives: 1. All patients are seen by the most appropriate provider. 2. Patients consistently receive appropriate, high quality, individualized care based on their own medical history and circumstances. 3. All patient encounters and problems are completely and accurately recorded so that a subsequent provider can confidently treat the patient. 4. Patients who are at high risk are readily identified and appropriate follow-up care is planned. 64 5. Tests and services requested by the primary provider are received, the results are reported back to the primary provider, and appropriate action is taken. 6. Long term (3-5 year) averaged outcomes show outcome improvements in decreased low birthweights, morbidity and mortality. Several of these objectives are met primarily through tke effective functioning of appointment, tracking and recall, referral, and medical records systems. For example, appointment systems and tracking systems can be designed to identify when patients need to be seen for particular types of visits and to highlight the special needs of high-risk patients. Risk assessment tools which are used on an ongoing basis by providers serve as an excellent tool for monitoring the risk status of all patients. A vell-functioning referral tracking system will help staff follow-up on outside services being provided for perinatal patients. The perinatal clinic manager is an important part of the quality assurance team because he or she has responsibility for designing and monitoring the related systems. Information about a number of systems related to a quality assurance program is discussed in previous sections. This section will include a discussion of the following components of a comprehensive quality assurance program for a perinatal program: 1. Health care plans. 2. Protocols for all aspects of care and mechanisms for adapting them to changes in information and staffing. 3. Checklists for monitoring the provision of all aspects of care. 4, Chart reviews and audits. 5. Peer review meetings to discuss specific cases or specific types of cases. 6. For large programs, a perinatal review committee. To carry out perinatal care most efficiently and effectively, services must be provided in the context of a logical and systematic health care plan. The plan should serve as a framework in which problems znd needs are identified, goals and objectives are established, resources are allocated, and progress toward meeting goals and objectives is evaluated. Most high quality perinatal programs develop fairly extensive protocols for providing both routine perinatal care and for dealing with the common and uncommon problems that might occur when treating a perinatal population. Detailed protocols are particularly important in settings vhere various types of providers are working with perinatal patients. As vell as outlining how routine and non-routine care will te provided, 65 protocols should also encompass types of services that will be provided by each type of provider. For example, a program which uses nurse practitioners, family practitioners, and obstetrician/gynecolcgists should define how patients will be divided among the different providers, when one type of provider will refer patients to another type of provider, and how the providers will monitor each others’ work. Althougt individual providers may feel that they understand these relationships for their setting, it is important that they be explicitly stated. Developing protocols can be a time consuming process. A program with no written protocols may choose to use another program’s protocols as a base and modify them as appropriate to the special needs of their patient population, the goals of the perinatal program, and the training and skills of their medical and educational staff. Modifications can be made by the medical director or by a committee composed of each type of provider of perinatal services. Some programs find it useful to form a permanent committee which regularly reviews and modifies the protocols and is responsible for circulating revisions to the rest of the medical staff. Protocols should be reviewed, updated and signed annually. In addition to standard medical protocols, it is useful to have protocols in place for the educational and social services prcvided by the perinatal and other health center staff. These protocols should detail the nutrition, health and parenting information needs of perinatal patients. They should also discuss which providers are primarily and secondarily responsible for providing the information, at what point(s) during the pregnancy the information should be provided, and how that information should be recorded in the medical record. : Detailed, well thought out protocols which accurately reflect what is being and should be done in the health center can serve as the basis for Quality Assurance Checklists. Checklists can be developed to track whether necessary medical information or test results have been received or whether particular nutrition or health education information has been given to the patient. For example, a short checklist can be included on the medical record which lists the various steps in the process of enrolling patients into the perinatal program: orientation appointment; lab work; payment paperwork; initial physical exam; initial meeting with nutritionist; and initial meeting with medical social worker. As each of these tasks is completed, it is checked off. When all items are checked off, the patient is considered enrolled and the slip is removed from the chart. The perinatal nurse manager is responsible for reviewing each chart before every clinic visit and scheduling those tasks which have not been completed. A detailed educational checklist (see Figure IV:A-1) can be made part of the perinatal patient’s medical record. The checklist includes a list of fairly specific activities and areas of education that should be covered during the perinatal period. Depending on the preferences of the staff, the checklist can take the place of writing extensive notes ir the medical records of non-high-risk patients. 66 Using the checklists discussed above, nursing and medical records staff should conduct periodic reviews of the medical records to be sure that all services that should have been provided have been rrovided and clearly recorded in the medical records. Any deviations should be noted and reviewed with the primary provider and/or the medical director. In addition, more extensive chart reviews should be periodically conducted by medical staff. One approach is for a medical staff member to be responsible for reviewing the charts of all patients at 28 weeks gestation, following delivery (mother and infant), and at eight weeks and one year for the infant. Programs which use CNMs and/or nurse practitioners and physician assistants to perform perinatal care often have a mechanism in place so that the charts of their patients are reviewed by a physician, although this may not be necessary if a good system of peer review is in place. Physician and other provider staff should meet on a regular basis (once per week, once per month) to thoroughly review a sample of perinatal charts and to discuss particular types of problems in detail. Newborn charts should be reviewed for "preventable interventicns" and with particular attention to the charts of low birthweight babies. Programs staffed only with physicians should also have this type of peer review session. G. Hospital Communication The goals of a system of communication between the health center and the hospital(s) where its patients will deliver should encompass: 1. Facilitating the relationship between the patient ard the hospital; 2. Facilitating the relationship between CHC and other physicians and the hospital. 3. Assuring that all prenatal information is available to the provider who will be performing the deliveries; 4. Assuring that all delivery information is relayed back to the health center. The specifics of the system of communication will depend on the specifics of the arrangements that have been worked out between the CHC and the hospital: i.e., who is responsible for paying the hospital bill; who is performing the delivery (CHC or hospital staff); will the hospital use the financial information that the CHC has gathered to apply a sliding fee scale to its full charges, etc. Once arrangements have been made with area hospitals for deliveries for the health center’s patients (see Section VI:A), there are three basic points during the perinatal period when communication between the health center and the hospital are particularly important: : 1) Introducing the patient to the hospital and the hospital to the patient So that the patient will know what to expect during her labor and 67 delivery and so that the hospital can get all of the financial and registration data it needs. At the latest, this meeting should take place early in the third trimester, either on an individual or group basis. Earlier meetings can be advantageous if special financing fcr inpatient care is being arranged. Optimally, a CHC perinatal staff member will be responsible for scheduling the visit and following up with both the hospital and the patient to make sure that it has occurred. At a minimum, perinatal patients should be given the name and telephone number of an individual to contact for a hospital orientation session. 2) Sending a copy of the medical record to the hospital. Early in the third trimester, usually at 28-30 weeks, but earlier fcr high-risk patients, a copy of the patient’s medical record should be sent to the hospital so that it can be available if there are problems late in pregnancy that require hospitalization or during labor ard delivery. Identifying which records should be copied each week shculd be the responsibility of the individual maintaining the perinatal log. A list can then be prepared for the medical records staff which can be responsible for copying and sending the record. A note should be made in the record of the date that it was sent. The results of each subsequent visit will also have to be copied and sent to the hospital. This function can be carried out by medical records personnel who will be able to tell from looking at the medical record if the bulk of the record has already been sent to the hospital. The hospital medical records supervisor should, of course, be contacted to determine his or her preferences for receiving ccpies of the records. Some hospitals request that the patient establish an inpatient medical record during the hospital orientation visit; the health center vould then reference the patient’s medical record number when sending a copy of the prenatal record. The need for coordination is particularly apparent in this effort, given the sheer volume of paper that will be sent from the CHC to the hospital(s). One alternative is to send the record later in the pregnancy or to provide the hospital with a sumrary of the record initially and then with monthly updates. The design of the summaries would have to be agreed upon by all providers involved in performing deliveries for a CHC patient. Another alternative is to give patients copies of their records and educate them about the importance of bringing them to the hospital. An understaffed CHC or one working with a large and/or disorganized hospital may find that a higher percentage of the patient-carried records make it into the hands of the delivering provider. 3) Receiving delivery and discharge information from tke hospital. Often, the CHC is largely at the mercy of the hospital in terms of receiving this information. It has a greater chance of receiving it if CHC staff have taken the time to work with hospital staff to identify each institution’s requirements. If patients have pre-registered, there is likely to be less confusion as to who should receive what paperwork. In addition, programs that use their own staff to perform the deliveries are more likely to receive the follow-up document (often addressed to the physician) than are programs that rely on house staff or contract physicians. The contract or letter of agreement between the Lospital and the health center should require timely receipt of the information. 68 H. Charges, Billing, Collection There are several goals in the development or refinement cf a charges, billing, and collection system for a perinatal program: 1. To cover the cost of the program to the extent pcssible given the resources of the patient population. 2. To charge individual patients an equitable amount fcr the services they receive based on their ability to pay. 3. To provide patients with information and counseling about the financial options available to them. 4, To encourage regular appointments and discourage sporadic use of services by patients. 5. To spread payment over the entire prenatal or perinatal period to minimize financial hardship. 6. To minimize the cost and maximize the efficacy cf the billing process. 7. To collect at least 80 percent of the amount that is billed to patients. 8. To facilitate payment for other perinatal costs, including delivery and hospital charges, by helping perinatal pstients identify the options available to them and understand the financial implications of each option. As with any community health center service, full charges should be based on the cost to the health center of providing those services. A sliding fee scale based on the federal poverty guidelines is then applied to the full charge and an individual patient’s bill is based on her ability to pay for the services. Calculating the cost of providing perinatal services can be more complicated than calculating the cost of other CHC services, particularly if the health center is covering services in addition to the basic medical and educational services, such as the provider's delivery fees or the cost of specialty services required by high-risk patients. In establishing a fee schedule for perinatal care services, a CHC must remember to ‘include the special costs related to providing perinatal services, such as malpractice insurance, compensation for on-call services, or additional staff such as a nutritionist or health educator. There are two basic ways of charging for perinatal services: on a per-service basis or as a package. Generally, package pricing is preferred. Package pricing is preferred because per-service or visit charges may discourage early entry into the perinatal system, regular use of the 69 services (women may skip prenatal visits to save money if they are not experiencing any difficulties), use of individual and group educational services, and use of other, often unanticipated services that can be very important in perinatal care. If the package option is chosen, per-service charges are often not offered, except in unusual cases. Full charge for the package should be based on entry into the system during the first trimester and include the full cost of providing the typical services plus some percentage of the cost of providing atypical but covered services. The same charge should be applied regardless of when the woman actually enters the system. The minimal fee should be the sum total of all minimal fees if each service was provided separately. In order to cover the high cost cf providing perinatal services, some programs have found it necessary to charge a higher minimum fee, particularly if delivery services are included. For example, a full charge of $500-$850 might be reduced to a minimum charge of $150. The CHC should also have a policy in place that outlines a pro-rated refund policy if the patient leaves the program because she miscarries or changes providers. A basic perinatal charge package should include: all medical perinatal visits, including the initial exam, basic laboratcry services provided at each visit, all prenatal visits and postpartum visits for the mother and baby; all individual counseling and educational sessions with the nurse, nutritionist, health educator, social worker and any other CHC personnel as determined to be needed by the patient’s primary provider; all group education classes provided by the perinatal program; all basic lab work; and prenatal vitamins. Depending on the center’s arrangements for deliveries, lab work, specialty referrals, specialized testing and so forth, the package could also include: the physician fee for a normal delivery, lab work for all medical visits to any health center provider during the prenatal period; any lab work ordered by the primary provider; ultrasound and non-stress testing as necessary; and partial or total payment for any outside referrals for medical and/or social services. Unless the CHC has its own birthing center or has worked out a particularly unusual deal with a local hospital, hospital charges should not be included as part of the package. Once a hospital has been chosen for a delivery, however, a CHC may want to introduce the patient to the hospital billing staff so that arrangements for payment can be made prior to the actual delivery. Per-service arrangements, how most or all other CHC services are billed, may be slightly easier to administer than package charges because they do not require a special billing arrangement. This type of arrangement may also be perceived of by patients as more equitable because they are paying for what they want and get rather than what the CHC staff think that they need. If a program chooses this charge approach the cost of the additional educational services needs to be recovered by the CHC. One option is to charge separately for counseling and educaticn sessions. Another is to incorporate the cost of these sessions into the charge for the medical visit and to schedule a patient so she receives a combination of services at each visit to the health center. 70 If perinatal services are provided on a per-service basis, the billing function can be completely integrated into the billing system of the rest of the center. Perinatal administrative personnel may want to assure, however, that all services provided by the program are included on the fee schedule or that the charge for medical visits covers the cost of providing other related services. Programs that have a package fee will need to develop a mechanism to spread the fee over the entire pre- cr perinatal period. One approach is to calculate the anticipated number of visits between the time the woman enters the perinatal system and Ler delivery date, divide the total charge by the number of visits, and charge the patient that amount at each visit. If the package also includes delivery fees the program may want to consider extending the payment period into the postpartum period, although collection rates are higher when full payment is expected before delivery. Patients are then billed at each visit and the usual procedure is followed for collecting the fee. In programs with centralized billing, collection rates (both at the time of service and overall) are higher if the perinatal staff become involved in some aspect of the billing and collection process. A special financial orientation meeting between the perinatal program administrator and each nev perinatal patient and her partner often aids in collection. The purpose of this meeting is four-fold: 1. To explain the costs and options of the program to the patient; 2. To provide financial counseling to the patient to determine if she is eligible for or receiving third party coverage such as medicaid, special state funding, or private insurance; 3. To detail the program’s expectations for payment; and, 4. To jointly work out an acceptable payment schedule. It is important to explain all of the components of the program so that patients know the full cost of the services they are receiving. This may also increase compliance with perinatal visit schedules because patients will have a better idea of what they are paying for and, in effect, the money that they are wasting if they don’t come for their visits. A payment schedule that is based on the individual patient’s financial circumstances and with the patient’s input is more likely to be followed. 2000 g) without risk factors, physiologic jaundice preeclampsia, premature labor at 32 weeks and later, mild to moderate respiratory distress syndrome, suspected neonatal sepsis, hypoglycemia, neonates of diabetic mothers, postasphyxia without life-threatening sequalae 117 24-26 weeks, severe maternal medical complications, pregnancy with concurrent cancer, complicated antenatal genetic problems, prematurity at 26-32 weeks (500-1250 9), severe respiratory distress syndrome, sepsis, severe postasphyxia, symptomatic congenital cardiac and other systems disease, neonates with special needs such as hyperalimentation, prolonged mechanical ventilation continued Perinatal Care Programs (continued) Level | Level ll Level I Location and number of births, neonatal beds Sq f/bed Chief of Service Other physicians Supervisory nurse Staff nurse: patient ratio Other personne Admission/ observation Family waiting Labor Located within Level Il or lll hospital or in sparsely populated or isolated areas; at least 1 birth/ day unless in isolated area Delivery/resuscitation 120 Admission/observation 40 Newborn nursery 20 Postpartum unit 100 One physician responsible for perinatal care (or co-directors from obstetrics and pediatrics) Physician (or certified nurse- midwife) at all deliveries, Anesthesia services Physician care for neonates RN in charge of perinatal facilities Normal labor 1:2 Delivery in second stage 1:1 Oxytocin inductions 1:2 ‘3sarean delivery 2:1 ‘mal nursery 1:6-8 +4, assistants under direction of ead nures : Close to labor and delivery, comfortable, room to ambulate Nearby/adjacent Single: 140 sq ft multiple, 80 sq ft/ patient Beds adjustable and moveable to delivery, may be used as birthing bed Full utilities, including auxiliary electrical, oxygen, suction Communication system Full routine patient care and CPR equipment Secure medication area Monitoring capabilities Medium and large communities. may be part of Level lil facility, several births/day, 3-4 neonatal beds. 1000 births served Space Level | plus: Intermediate nursery 50 Continuous/convalescent nursery 30 Personnel Joint planning: Ob: Board-certified obstetrician with certification, special interest, experience, or training in maternal-fetal medicine; Peds: Board-certified pediatrician with certification, special interest, experience or training in neonatology Level | plus: Board-certified director of anesthesia services Medical. surgical, radiology, pathology consultation Ob: RN with education and experience in normal and high- risk pregnancy only responsible Peds: RN with education and experience in treatment of sick neonates only responsible Level | plus: Complicated labor/delivery 1:1 Intermediate nursery 1:3-4 Level | plus: Social service. biomedical. respiratory therapy. laboratory as needed Obstetric Units Level | plus: Beds, space for diagnostic procedures, possible emergency delivery Level | Level | 118 Medium and large ——— usually in academic centers, several births/day. 1 intensive care neonatal bed/1000 births served in addition to Level Il Levels | and Il plus: Intensive neonatal 80-100 Codirectors: Ob: Full-time board-certified obstetrician with special competence in maternal-fetal medicine; Peds: Full-time board-certified pediatrician with special competence in neonatal medicine Levels | and Il plus: Anesthesiologists with special training or experience in perinatal and pediatric anesthesia Obstetric and pediatric subspecialists Supervisor of perinatal services é with advanced skills Separate head nurses for maternal- fetal and neonatal services Levels | and Il plus: Intensive neonatal care 1:1-2 Critical care of unstable neonate 2:1 Levels | plus: Designated and often full-time social service. respiratory therapy. biomedical engineering, laboratory technician Nurse-clinician and specialists Nurse program and education coordinators Levels | and Il plus: Other bed designated for observation Level | Level | continued Perinatal Care Programs (continued) Birthing (labor/ bp delivery/recovery) Delivery (vaginal and operative) Antepartum and postpartum area Resuscitation Admission/ observation Newborn nursery Continuing care Intermediate care Intensive care Pp Level | Combined equipment for labor and delivery, may be concealed Adequate space, equipment for ambulation, support person Contiguous to labor; at least two available, with one equipped for cesarean delivery Operating room in design Equipment/supplies necessary for normal delivery and management of complications, including surgical intervention Contiguous with nursery Large enough to accommodate mother, baby, visitors Maximum two mothers/room 100 sq ft/patient in multiple patient rooms Communication system Hospital standard utilities 100 foot-candles illumination Overhead radiant heat Heating pad Wall clock Resuscitation and stabilization equipment . Designated area (40 sq ft) or room (120 sq ft) Full utilities, including suction, oxygen, compressed air, electrical outlets Near or adjacent to delivery/ cesarean birth room, may be part of maternal recovery area 40 sq fneonate Equipment as in resuscitation area Close to postpartum area Beds and equipment to exceed obstetric beds by 20%-30% 20 sq f/neonate Resuscitation equipment 1 electrical outiet/2 beds 1 O,, air suction/5-8 beds Usually not located in Level | Not present Not present Level Il Level | Level | (Actual number of delivery rooms depends on total births) plus: Intensive care room in labor/ delivery area for patients with significant complication Level | Nursery Level | May be located in newborn or continuing care area Level | Near intermediate nursery. 30 sq f/neonate Resuscitation equipment 4 electrical outlets 1 O,, 1 air, 1 suction/neonate Near delivery and intensive care nurseries Full life support and monitoring in addition to resuscitation equipment 50 sq f/neonate 8 electrical, 2 0,, 2 compressed air, 2 suction outlets/neonate Present in some hospitals Ancillary Support Technicians on call 24 h/day, available within 15-30 min Technicians immediately available for emergency situations 119 Level Ill Level | Levels | and I! plus: Intensive care area Level | Level Il Level | Level II Level Il Near delivery/cesarean birth rooms - 80-100 sq ft/neonate 12 electrical, 2 O,, 2 compressed air, 2 suction outlets/neonate Full life support, monitoring and resuscitation equipment Level Il, may be in delivery room area continued Perinatal Care Programs Level Il Level lll Level | Laboratory (microtechnique for neonates) Within 15 min Hematocrit Within 1 h Glucose, BUN, creatinine, blood gases, routine urinalysis Within 1-6 hr CBC, platelet appearance on smear, blood chemistries, blood type and cross matched, Coombs’ test, bacterial smear Within 24-48 hr Bacterial cultures and antibiotic Within hospital or facilities available Radiography and ultrasound Blood bank Technicians on call 24 hr/day, sensitivity Viral cultures Technicians on call 24 hr/day, available in 30 min Technicians experienced in performing abdominal, pelvic and OB ultrasound examinations Professional interpretation available on 24 hr basis Portable x-ray and ultrasound equipment available to labor and delivery rooms and to nurseries Blood gases, blood type and Rh Level | plus: Electrolytes, coagulation studies, Level Il Levels | and Il plus: Special blood and amniotic fluid blood available from Type and tests Screen program Level | plus: Levels | and Il Coagulation studies. magnesium, urine, electrolytes, and chemistries Level | plus: Levels | and lI Liver function test, Metabolic screening Level | Level | plus: Laboratory facilities available Experienced radiology technicians Level Il plus: immediately available in hospital (ultrasound on call) Professional interpretation immediately available Portable x-ray equipment Ultrasound equipment may be in labor and delivery or nursery areas Sophisticated equipment for Computerized axial tomography emergency GI, GU or CNS studies available 24 hr/day Experienced technicians Level ! plus: available in 30 min, performing routine blood banking procedures Pelvic examination Culture of cervix and uterus Examination and treatment room Parent education Conference room Locker room (may be remote) Physician on-call room nearby Auxiliary areas Laboratory within unit for hematocrit, centrifuge for dip stick for urine, albumin, glucose, microscope immediately available in hospital for blood banking procedures and identification of irregular antibodies Blood component therapy readily available Level | plus: Amniocentesis Equipment for removal of suture for cerclage Level | plus: Breast-feeding area within unit Parent waiting room for intensive care ‘ Level | plus: Refrigerator to hold cultures, materials Gram stain material Resource center for ne.work Direct line communication to labor and delivery area and nurseries Levels | and Il plus: Services within unit Levels | and |i plus: All areas within unit Conference/lecture rooms as necessary for professional/ regional education commitments Levels | and Ii American Academy of Pediatrics and American College of Guidelines for Perinatal Care, 1983. Gynecologists. ¢rU.8. GOVERNMENT PRINTING OFFICE: 1985 461 20490 120 Obstetricians and Pages 246-253. BHCDA U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Health Resources and Services Administration Bureau of Health Care Delivery and Assistance U.C. BERKELEY LIBRARIES | J WIAD BOO11kL9217