Our mission is to improve the health

and quality of life of our members

2017

Mommy Steps

Program Descriptions

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Mommy Steps Program Descriptions

I. Purpose Passport Health Plan (Passport) has developed approaches to the management of members’ high risk obstetrical condition(s) in order in improve birth outcomes such as prematurity and low (LBW), and very low, birth weight (VLBW). The emphasis of the Mommy Steps Program is education and support for targeted members and clinicians to improve the overall health, wellness, and quality of the member’s life. The Mommy Steps Program will facilitate member understanding and responsibility of the high risk pregnancy process as well as coordination of care between the member and/or caregiver and the clinician. The Mommy Steps Program focus is on emphasizing prevention of complications by providing support and care coordination to increase compliance with Passport’s Perinatal Care Clinical Practice Guidelines which are based on the American Congress of Obstetricians and Gynecologists (ACOG) Guidelines1 utilizing patient empowerment strategies.

II. Program Goals Increase percentage of members who receive prenatal care within 42 days of enrollment or

within the first trimester.

Increase average number of prenatal visits to 80% or greater of the expected visits per member to encourage regular prenatal care.

Increase percentage of members who receive a postpartum clinician visit between 21 and 56 days after delivery.

Decrease the number of preterm deliveries (≤ 37 weeks).

Decrease the number of LBW (1,501 grams to < 2,500 grams) babies to 5% or less.

Decrease the number of VLBW (< 1,500 grams) babies to 1% or less.

III. Rationale 1. National

According to the 2014 March of Dimes PeriStats, 9.6% of all live births in the United States were preterm, or 1 in 10.2 In addition, 8.0% were LBW and 1.4% was VLBW.3

2. Kentucky

According to the 2014 March of Dimes PeriStats, 10.7% of live births in Kentucky were preterm, or 1 in 9. In addition, 8.8% were LBW and 1.5% was VLBW3. Risk factors for LBW and VLBW include smoking, alcohol, street drugs, and abusing prescription drugs, little education, low income, being unemployed, age, race and/or ethnicity.4

1 http://passporthealthplan.com/wp-content/uploads/2014/11/prov-40473-perinatal-care2.pdf 2 http://www.marchofdimes.org/Peristats/ViewSubtopic.aspx?reg=99&top=3&stop=55&lev=1&slev=1&obj=3 3 http://www.marchofdimes.org/Peristats/ViewSubtopic.aspx?reg=99&top=3&stop=64&lev=1&slev=1&obj=1 4 http://www.marchofdimes.org/complications/low-birthweight.aspx

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Major risk factors for preterm birth include a history of preterm birth, current multiple gestation pregnancy, some uterine/cervical abnormalities, infection (especially genito-urinary), diabetes mellitus, hypertension, late or no prenatal care, smoking, alcohol, and illicit drug use.1

3. Passport

In 2016, Passport had an average of 2,739 members per quarter enrolled in the Mommy Steps Program, with an average of 1,210 members per quarter that were identified as new members, a 10% increase from 2015. There was an average of 405 members per quarter identified as high risk. They are selected to be both high risk and most likely to be assisted by active Case Management. This required a reassessment of our triage protocol to ensure that our efforts were being increasingly directed toward those members most likely to benefit from active Case Management. Because of this change in criteria, there was a 66% decrease in the number of actively managed patients in the Mommy Steps Program’s compared to 2015, with an increased emphasis on more frequent contacts with the members most likely to benefit from active case management, Care Coordination, and support2.

An average of 781 high risk members per quarter were actively engaged and received one-on-one telephonic contact and educational materials from a High Risk OB Case Manager, a 57% increase from 2015. There was an average of 471 members per quarter who received postpartum outreach calls, an 82% increase from 2015. An average of 377 referrals per quarter was made to WIC, HANDS and Healthy Start, a 6% decrease from 2015. New members received individual educational mailings. The Mommy Steps High Risk OB Case Managers collaborated with Utilization Management (UM) OB Embedded Case Managers to ensure members needs and resources were provided.

Ability to impact birth outcomes:

Potential areas of impact (in addition to a reduction in healthcare costs)

Education of pregnant members, pre-current and post-pregnancy management, increase the percentage of deliveries at ≥ 37 weeks gestation, increase the frequency of prenatal visits for gestational age, ensure members receive adequate prenatal care, increase compliance in relation to recommended postpartum visits to reduce postpartum complications, reduce the rate of LBW and VLBW infants, decrease the frequency of elective induction or delivery at < 39 weeks gestation, decrease smoking rates and the rate of maternal and infant postpartum readmissions, and improve the quality of life of members.

IV. Member Participation Eligible members have the option to enroll in the Mommy Steps Program. Participation, however, is voluntary and the member has the right to “opt out” of the Mommy Steps Program or decline all or any part of it. Members who “opt out” may “re-enter” the Mommy Steps Program at any time by contacting the High Risk OB Care Advisor or the Care Connection Program, either verbally or in writing.

1 http://www.marchofdimes.org/Peristats/pdflib/195/21.pdf 2 This decrease is due from a change of member stratification for what is considered high risk for the Mommy Steps Program

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V. Integrating Member Information1 Passport utilizes Identifi, an integrated medical management technology platform, in order to allow all health plan staff access to member information. In Identifi, all users are able to view information that is specific to the member such as demographics, eligibility, member’s clinician, spoken language, and preferences on receiving educational materials or phone contact. Users also have the ability to enter additional addresses or phone numbers, which the member may give as an alternative way to reach him/her that is not associated with the state file download that populates the basic demographic fields in Identifi. The Patient View may be utilized to denote a caregiver name and phone number, as needed.

In addition, Identifi users can perform the following activities:

Edit demographic information and preferences, as needed.

Upload documents related to the member and/or the member’s care that need to be visible to all users in order to facilitate seamless care coordination.

View all the documentation that has been entered as it relates to the member.

View any correspondence that the member has sent to Passport, or that Passport has sent to the member.

View the member’s established care coordination assessment and plan of care.

View claims, both pharmacy and medical, related to the member.

View results of labs/screenings, as available.

View a clinical summary/history of the last six months of the member including tests and services, medical conditions, medications, emergency room (ER) visits, inpatient (IP) admissions, office visits, etc.

View historical data or “closed” cases.

All of this data allows everyone interacting with the member to have access to the most current and available data in order to make every member contact count to its fullest potential and improve coordination of care by all users having the same information.

VI. Population Identification Eligible members for the Mommy Steps Program are identified primarily through clinician notification of pregnancy to Passport but can include the following:

Data collected through the UM process, examples include, but are not limited to, hospital census report, ER Utilization reports, and Embedded UM

Data collected through the Care Connection Program health and wellness outreach representatives

Referrals from clinicians – This includes, but is not limited to, OB clinicians, Departments of Health (DOH), and Teen Pregnancy programs

Referrals from other Passport departments, examples include, but are not limited to, Case Management (CM), Disease Management (DM), EPSDT, Member Services, or Stork Care

Referrals from subcontractors – This includes, but is not limited to, 24/7 Nurse Health Information Line

Self-referrals from members

Referrals from hospital educators/discharge planners

Data collected through the Health Risk Assessment Form (HRA)

Data collected through the weekly Pregnancy Report (PRG)

1 In July of 2017, the Mommy Steps Program will utilize the Lucina Firefly Maternity Informatics Platform for clinical record management of the maternity population.

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Members who meet the criteria are eligible for the Mommy Steps Program. This determination of eligible members occurs on a daily basis. In addition to identifying members on a daily basis, members may be adjusted from low risk to high risk.

Program Participation Requirements:

Age Diagnosis Continuous enrollment Utilization Pharmacological

All pregnant members

Pregnancy All enrolled pregnant members

N/A N/A

VII. Member Contact Eligible members are identified weekly and receive one of the following welcome packets depending on known and unknown risks, including:

Welcome letter for members with known risks (Appendix A), or

Welcome letter for members with unknown risks (Appendix B), and

Pregnancy Screening Tool (Appendix C).

Both welcome packets will include information on:

Smoking cessation resources

The importance of early and regular prenatal care

Community resources such as WIC, HANDS, Healthy Start

Care Messaging Program

Available treatment for drugs and alcohol, mental health services

Domestic violence support line

Dental and vision service contacts

Legal assistance contacts

Support group information for loss of an infant

State transportation service contact numbers

Members who call Passport are screened for any high risk conditions that could result in poor birth outcomes, demographics are verified, and members are given the Care Connector Program contact numbers to call with any questions or if anything changes during the member’s pregnancy.

In addition, the members receive:

Assistance with rescheduling missed OB appointments and overcoming barriers that may contribute to further missed appointments, such as transportation and language barriers.

Postpartum telephonic outreaches to screen for postpartum complications, educate on the importance of scheduling a postpartum visit, newborn visits, assist with newborn enrollment with Medicaid and Passport, other available resources, and answer any questions.

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All identified pregnant members with any of the following will be considered high risk (Appendix D):

Substance Abuse

Homelessness

Domestic Violence

Teen Pregnancy (18 years and younger)

Chronic Hypertension (CHTN)

Diabetes (Type 1, Type 2 and/or Gestational Diabetes (GDM))

History of Pre-term Delivery (<37 weeks)

Triage (for Mommy Steps Team only)

Pregnant members identified as high risk receive outreach from a High Risk OB Care Advisor. The High Risk OB Care Advisor:

Assesses the member’s needs utilizing a maternity-specific assessment.

Coordinates care with the clinician involved in the member’s care.

Establishes and maintains contact with the member to evaluate and revise the plan of care as needed.

Educates the member and/or caregiver on the importance of medication adherence, attending scheduled appointments, adherence with self-monitoring activities, and adherence with screenings/lab tests.

Educates the member and/or caregiver on lifestyle changes that may improve the member’s birth outcome such as diet/weight management, medication adherence, exercise, smoking cessation, avoidance of drugs and alcohol, and regular clinicians’ visits.

Outreach to members continues throughout eight weeks postpartum.

Conducts the Patient Health Questionnaire (PHQ) 2 at postpartum as a depression prescreening tool and based on the results, completes the Edinburgh Postnatal Depression Scale (EPDS) Assessment, to identify members in need of referral for behavioral health services.

Provides the member with assistance/information regarding available community resources.

Provides the member and/or caregiver with additional written and/or verbal information targeted to the member’s specific diagnoses.

VIII. Clinician Notification and Involvement Participating clinicians in the health plan are notified of the Mommy Steps Program by the following:

Quick Reference Guide distributed to new clinicians with information regarding how the High Risk OB Care Advisor works with pregnant members and instructions on how to access and utilize the program services (Appendix E)

The Passport Provider Manual

The Passport Provider Website @ www.passporthealthplan.com

eNews

Clinician outreach visits by the Provider Relations Department and/or High Risk OB Care Advisor

Passport’s Perinatal Care Clinical Practice Guidelines are available to all participating clinicians. Guidelines are reviewed and updated at least every two years and anytime new scientific evidence is published.

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IX. Member Satisfaction with the Mommy Steps Program

Passport’s Mommy Steps Program has a Member Satisfaction Survey Postcard (Appendix F) that is mailed out to members regarding the Mommy Steps Program directing them to the Passport website to complete the survey. Members have the option to call the Care Connectors and have a hard copy of the satisfaction survey (Appendix G) mailed to them to complete. Questions address member experiences with the Mommy Steps Program and the High Risk OB Care Advisor in the areas of:

The effectiveness in helping the member understanding high risk pregnancy.

The helpfulness in assisting the member developing a self-management plan.

The helpfulness in assisting the member adhering with the established self-management plan.

The usefulness of the educational materials provided.

The ability of the High Risk OB Care Advisor to listen to the member.

The helpfulness of the High Risk OB Care Advisor to assist the member in care coordination.

The survey results are tracked and analyzed to identify opportunities to improve satisfaction with the Mommy Steps Program. Results are reported quarterly by the Manager of High Risk Maternity Management or his/her designee, with the goal of 90% or above in member satisfaction with all areas of services. The member has the option to be contacted by the Manager of High Risk Maternity Management or his/her designee, regarding inquiries about the Mommy Steps Program. Two (2) attempts are made by the Manager of High Risk Maternity Management or his/her designee, to contact the member. If outreach is unsuccessful, then the Manager of High Risk Maternity Management or his/her designee, will send out the Satisfaction Survey Return Call Letter (Appendix H) and wait two (2) weeks for a reply. All outreach to the member are tracked for reporting purposes. Complaints and/or inquiries regarding the Mommy Steps Program can be received by Member Services or through the Care Coordination Department. Complaints and inquiries through Member Services are documented in EXP, a customer-service software package that records, tracks, and reports on all member and clinician inquiries and complaints allowing for real-time on-line communication between departments. Complaints or inquiries through the Care Coordination Department are resolved in the Care Coordination Department and then forwarded to Member Services for documentation in EXP. Additionally, all member complaints regarding services are forwarded to the Manager of High Risk Maternity Management or his/her designee, for follow-up. The Manager of High Risk Maternity Management or his/her designee, conducts a quantitative and qualitative analysis of complaints and inquiries regarding services, annually. This analysis is used to identify patterns of member complaints and opportunities to improve satisfaction with the Mommy Steps Program. Changes to the Mommy Steps Program are made as needed.

X. Annual Evaluation

The annual evaluation of the Mommy Steps Program is conducted by Passport’s High Risk OB Care Advisors, the Manager of the High Risk Maternity Management, the Director of Medical

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Management Care Coordination, the Medical Director of Women’s Health, the Director of Quality, and the Chief Medical Officer, or designee.

Objectives, activities and outcomes are evaluated at a minimum of annually in order to:

Measure participation rates.

Determine whether the Mommy Steps Program has demonstrated improvement in birth outcomes and quality of care provided to pregnant members.

Evaluate the overall effectiveness of the Mommy Steps Program.

Allow for exploration of barriers and limitations of the Mommy Steps Program.

Revise areas as needed to improve effectiveness of the Mommy Steps Program.

Formal measurements of Frequency of Ongoing Prenatal Care, Initiation of Prenatal Care and Postpartum Care are performed annually through HEDIS®1 reviews using HEDIS® methodology. Program goals for LBW, VLBW, and Preterm Births are based on Healthy People 2020 and are measured on delivery information obtained through facility notification of delivery. Results are utilized to revise the program and set the program goals for the following year. More frequent barrier analyses are performed on an ongoing basis and adjustments to the Mommy Steps Program are made accordingly.

Final approval by the Quality Medical Management Committee: May 6, 2014 August 14, 2015 June 14, 2016 May 16, 2017

1 HEDIS® is a registered trademark of the National Committee of Quality Assurance (NCQA).

Appendices

A. Welcome Letter for Members with Known Risks B. Welcome Letter for Members with Unknown Risks

C. Pregnancy Screening Tool

D. Welcome Packet Resources

E. High Risk Stratification Tool

F. Provider Quick Reference Guide

G. Provider Orientation Kit

H. Mommy Steps Program Satisfaction Survey Postcard

I. Mommy Steps Program Satisfaction Survey

J. Mommy Steps Satisfaction Survey Return Call Letter

Member Welcome Letter for Members with Known Risks Appendix A

[Date] Congratulations on your pregnancy! The maternity program at Passport – called Mommy Steps – knows that becoming a mom is a big step in your life. Your prenatal care, the care you get during pregnancy, is very important and will help you have a healthy pregnancy. Understanding what to do can put you at ease and will make all the difference.

3 Steps to a Healthy Pregnancy: 1. Attend all of your regular doctor visits and prenatal appointments. 2. Eat healthy foods. 3. Make good choices – do not smoke, use alcohol or drugs. If you have any major changes in your pregnancy, please tell your doctor and give us a call at 1-877-903-0082. You may call us Monday through Friday from 8 am to 6 pm Eastern Time. TDD/TTY users please call 1-800-691-5566. Si habla Espanol, por favor llamme Pasos de Mama: 1-877-903-0082.

Sincerely,

Mommy Steps EVOH73499 APP_4/17/2017

Remember! To keep your Passport benefits, DCBS/Medicaid needs your most recent address on file at all times. Please report any address changes to the office where you applied for Medicaid — the DCBS office, SSI office or Benefind. If you have questions, you may call our Member Services team at

1-800-578-0603.

Member Welcome Letter for Members with Unknown Risks Appendix B

[Date] Congratulations on your pregnancy! The maternity program at Passport – called Mommy Steps – knows that becoming a mom is a big step in your life. Your prenatal care, the care you get during pregnancy, is very important and will help you have a healthy pregnancy. Understanding what to do can put you at ease and will make all the difference.

3 Steps to a Healthy Pregnancy: 1. Attend all of your regular doctor visits and prenatal appointments. 2. Eat healthy foods. 3. Make good choices – do not smoke, use alcohol or drugs.

We’d like to learn more about you and your health needs. Please fill out the enclosed Pregnancy Screening Tool and mail it back in the postage-paid envelope. If you have any major changes in your pregnancy, please tell your doctor and give us a call at 1-877-903-0082. You may call us Monday through Friday from 8 am to 6 pm Eastern Time. TDD/TTY users please call 1-800-691-5566. Si habla Espanol, por favor llamme Pasos de Mama: 1-877-903-0082.

Sincerely,

Mommy Steps EVOH73497 APP_4/17/2017

Remember! To keep your Passport benefits, DCBS/Medicaid needs your most recent address on file at all times. Please report any address changes to the office where you applied for Medicaid — the DCBS office, SSI office or Benefind. If you have

questions, you may call our Member Services team at 1-800-578-0603.

Pregnancy Screening Tool Appendix C

Pregnancy Screening Tool Appendix C

Welcome Packet Resources Appendix D

Welcome Packet Resources Appendix D

Welcome Packet Resources Appendix D

Welcome Packet Resources Appendix D

*NOTE: This flyer is awaiting DMS approval

Welcome Packet Resources Appendix D

Welcome Packet Resources Appendix D

Welcome Packet Resources Appendix D

Welcome Packet Resources Appendix D

Welcome Packet Resources Appendix D

High Risk Stratification Tool Appendix E

Provider Quick Reference Guide Appendix F

Provider Orientation Kit Appendix G

Mommy Steps Program Satisfaction Survey Postcard Appendix H

Mommy Steps Program Satisfaction Survey Appendix I

Mommy Steps Satisfaction Survey Return Call Letter Appendix J

[Date] [Member] [Address] [City, State, Zip] Dear Member, We have received your Satisfaction Survey and see that you would like to speak with someone at Passport. I am very happy to talk with you and help answer your questions. However, I have been unable to reach you by phone. You may call me back at 1-877-903-0082, press 0, then press [ext]. I look forward to hearing from you! Sincerely, [Name and Credentials] [Title] Passport Health Plan HLTH40658 APP_10/7/2014