Maternal Medical Home Process Evaluation

The Maternal Medical Home model of care was designed to support women’s psychosocial needs during pregnancy to achieve better birth outcomes. The model was designed collaboratively with the local public health authority, the local coordinated care organization and local prenatal providers to establish care standards that prenatal clinics must follow to be designated a Maternal Medical Home. Clinics with that designation are eligible for an enhanced payment by the coordinated care organization for those patients on Medicaid. While the health outcomes evaluation of this care model has been established, a clear process evaluation had not. This project designed a comprehensive process evaluation to address this critical gap. Running head: MATRERNAL MEDICAL HOME PROCESS EVALUATION 3 Introduction Clinical Problem In 2014, the Unites States (US) birth rate was 12.5%, a slight increase from 2013 (National Vital Statistics Report, 2015). Of those births, 44.9% were to women on Medicaid (Markus, Andres, West, Garro, & Pellegrini, 2013). According to data from the National Center for Health Statistics, the overall infant mortality rate in the US is 6% (2013). This is higher than other developed countries such as Finland and Japan, both with a rate of 2.3% (Centers for Disease Control, 2010). Even after removing births that occurred prior to 24 weeks gestation, the US still has a rate of 4.2%, twice that of many other countries (MacDorman & Mathews, 2009). Women and infant health outcomes have long been thought of as concerns that need to be managed on an individual level between a woman and her provider. However, as population health has been defined as one of the pillars of healthcare transformation, taking a population and systems approach to reducing poor outcomes is being explored in new ways (Johnson, 2016). Consideration and understanding of the psychosocial risk factors that play into pregnancy and birth outcomes and how to influence them is beginning to take shape. Comprehensive coordinated services during pregnancy are a critical factor in healthy outcomes and managing healthcare costs (Rakover, 2016). A focus on standardized risk assessment, entry to care in the first trimester, and care coordination services has been shown to improve birth outcomes (Berrien, Ollendorf, & Menard, 2015). Additionally, standardization of medical practices related to particular pregnancy health concerns coupled with strategic roll out in clinics has also improved birth outcomes in participating clinics (Berrien, et al., 2015). A comprehensive care model has been created based on the literature related to addressing psychosocial health during pregnancy to improve birth outcomes and will be piloted in a prenatal practice. While the model has established health outcome measures to evaluate the pilot’s impact on health and financial Running head: MATRERNAL MEDICAL HOME PROCESS EVALUATION 4 costs, it did not have a mechanism for understanding why the model may or may not be successful. Process evaluation is a way to answer the ‘why’ question. Planning and conducting a process evaluation will allow the team of people planning, implementing, and evaluating the pilot to know why outcomes were or were not achieved (Sanders, Evans & Joshi, 2005; Hulscher, Laurant, & Grol, 2002). In addition to being valuable after the pilot is reviewed, process evaluation during the intervention can provide important insight to know if modifications are needed during the implementation phase (Hulscher, Laurant, & Grol, 2002). The purpose of this project was to develop a process evaluation for the developed Maternal Medical Home care model. Review of the literature Psychosocial supports are elements of a person’s life that support their psychological, behavioral and emotional health and wellbeing (Hobel, Goldstein, Ma & Barrett, 2008). Significant research exists linking psychosocial risk factors such as maternal stress, maternal smoking, depression, anxiety and racial discrimination to health outcomes, specifically preterm deliveries and low birth weight births (Accort, Cheadle & Dunkel, 2015; Grote, Bridge, Gavin, Melville, Iyengar et al., 2010; Neggers, Goldenberg, Cliver & Hauth, 2006; Dunkel & Tanner, 2012; El-Monhandes, Kiely, Gantz & El-Khorazanty, 2010; Hobel, Goldstein, Ma & Barrett, 2008; Tierney-Gumaer & Reifsnider, 2008; Borders, Grobman, Amsden & Holl, 2007). While research demonstrates connections between psychosocial risk factors and health outcomes, the literature regarding psychosocial interventions and the connection to improving health outcomes is less clear. There is strong evidence that psychosocial risk factors influence birth weight and gestational age and that the use of behavioral and social interventions decrease psychosocial risk factors during pregnancy, what was not found in the literature was proof that decreasing psychosocial risk factors during pregnancy had a positive impact on birth outcomes (Uchino, Running head: MATRERNAL MEDICAL HOME PROCESS EVALUATION 5 Bowen, Carlisle, & Birmingham, 2012; El-Mohandes, Kiely, Gantz, & El-Khorazaty, 2011). In essence, psychosocial risk factors negatively impact birth outcomes, there are ways to decrease these risk factors but decreasing them during pregnancy has not demonstrated a positive impact on birth outcomes. The gap in what is understood is how to impact psychosocial risk factors in a way that has a positive impact on birth outcomes. More research is needed to have better understanding of this. One concept specifically called out in literature is the co-occurring nature of psychosocial risk factors and the need to address them simultaneously to make an impact. A potential strategy to address this need is putting all of the various elements that have been proven successful (screening, care coordination, and behavioral health supports) together to create a comprehensive model that will simultaneously address the psychosocial risk factors as well as assure the important physical elements of prenatal care are achieved. The creation of the Maternal Medical Home is a strategy in which physical and psychosocial risk factors are addressed in an effort to begin seeing positive shifts in US birth outcomes. A critical factor in understanding the success and challenges of this pilot care model will be the implementation of a process evaluation that will provide details on the implementation process (Schneider, Hall, Hernandez, Hindes, Montez, Pham, Rosen, et al., 2009). The focus of this project has been to design a comprehensive process evaluation that will allow those providing oversight to the pilot a clear understanding of the pilot care model and how it is anticipated to be implemented, establish the intent of the process evaluation, and determine the resources needed to conduct the process evaluation (Sanders, Evans & Joshi, 2005). While the pilot project includes health outcome data collection and evaluation, the establishment of and conducting a process evaluation will allow those reviewing the pilot to know if it has been executed as planned as well as understand why it was successful or unsuccessful. In addition, a process evaluation may be beneficial in determining the care models Running head: MATRERNAL MEDICAL HOME PROCESS EVALUATION 6 potential for replication (Sanders, Evans & Joshi, 2005). Having a strong process evaluation with built in check points will provide the opportunity to make necessary changes in a systematic and intentional way, when needed, during the implementation period (Hulscher & Laurant, 2002). The Maternal Medical Home Care Model Pilot The Maternal Medical Home care model has been designed to address the psychosocial needs of women in addition to physical health needs through assessment, intervention, connection to resources, and care integration. Clinics that meet the standards and expectations to become a Maternal Medical Home receive an enhanced payment for Medicaid patients. The standards and expectations of Maternal Medical Homes are the following: • Standardized Psychosocial ScreeningThe clinic will utilize the Family Wellbeing Assessment, a standardized tool developed by the Oregon Perinatal Collaborative, at the first or second prenatal appointment. • Behaviorist ServicesThe clinic will employ a behaviorist in the clinic to provide behavioral health screening and intervention, behavior modification support, and coordination to mental health services as needed. • Care Management and Care CoordinationThe clinic will integrate a public health maternal child health nurse into practice to provide home visiting, care coordination and case management. • Effective Contraception Screening: The clinic will complete pregnancy intentionality screening for all members in the third trimester of pregnancy and the postpartum visit. • Postpartum Care Monitoring, Tracking and Follow UpThe clinic will track women seen for postpartum care and follow up with those who have not been seen. • Primary Care Provider Linkage: The clinic will assure identification of a primary care Running head: MATRERNAL MEDICAL HOME PROCESS EVALUATION 7 provider for moms and babies after delivery and support the transition of care to the PCP, as needed. • Tobacco Cessation EffortsThe clinic will provide and track cessation referrals The following data will be collected and monitored throughout the intervention. Approach to the Conduct of the Project Setting and Participants The Maternal Medical Home pilot site is an obstetrical/gynecological care clinic in a mid-sized Oregon county with a population of approximately 100,000 residents. The clinic is one of four that provide prenatal care in the county. It is composed of both physicians and midwives, and serves publicly (Medicaid) and privately insured patients. The development of the process evaluation happened in conjunction with the pilot clinic site to allow for input and shared decision making with the prenatal providers. The high level o