puff free pregnancy® - national healthy start · national healthy start association 12th annual...

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Puff Free Pregnancy® Effectiveness of the Program on an

Ohio Medicaid Population

Janice Linehan PA-C Amy Poole-Yaeger MD

NATIONAL HEALTHY START ASSOCIATION 12TH ANNUAL SPRING CONFERENCE 2

Puff Free Pregnancy

Today’s Presentation

• Introduce the Start Smart for your Baby® Program

• Review health issues surrounding smoking during pregnancy

• Describe the Puff Free Pregnancy Program

• Demonstrate program outcomes

• Discuss the future direction of program


Centene Corporation

• Provides health plans, programs and related services

– Managed care of government sponsored programs – Medicaid, TANF, SSI, SCHIP, foster care, special needs plans

– Health plan services offered in 10 states with multiple product lines

– 7 health management companies, including Nurtur, our disease management partner in Puff Free Pregnancy

• 1.7 million members

– Children – Women who are pregnant – Adults (aged, blind, disabled) – Foster care – Long-term care


Start Smart for Your Baby

• Centene-wide, comprehensive pregnancy management program

• Wellness and Disease Management

• Case management • Care coordination

• Supports educational and social

needs

• Extends from pre-conception to the first 1-2 years of life of the child

URAC Best Practice Platinum Winner

URAC/GKEN Best Practice Winner

http://www.urac.org/accreditationEducation/11thAnnualSummit.asp


Goals of Start Smart

•Case manage high-risk pregnancies •Reduce adverse health care events

•Educate and empower members to take part in improving their health and the health of their unborn babies and newborns •Improve birth outcomes such as:

• Fewer low birth weight deliveries • Fewer neonatal ICU admissions • Fewer neonatal ICU days / 1000 births


The Centene Pregnancy Landscape

• Our pregnant member ethnic makeup is diverse

• Average age of pregnant women in our plans is approximately 24.5 years

• Most (around 80%) of our pregnant women have at least a high school education

Asian

1%

African-

American

28%

Caucasian

20%Hispanic

21%

Native American

0%

Unknown

30%


Multifaceted Approach Involves All Parties and Has Multiple

Touch-points


The Notification of Pregnancy Form

• Identifies pregnant members as early in pregnancy as possible

•Provider version and member version

•Assigns proprietary risk score

•Case management referral of high-risk members


Pregnancy and Smoking - Incidence

• Pregnant Medicaid women are 2.5 times more likely to smoke than those not on Medicaid1

• Pregnant Medicaid women have a higher smoking

prevalence (24%) compared to those with private insurance (7%)2

• Based on our NOP data – 10-15% of our pregnant members are documented smokers

Source: 1. Lipscomb LE, Johnson CH, et al. PRAMS 1998 Surveillance Report. Atlanta: Division of Reproductive Health,

National Center for Chronic Disease Prevention and Health Promotion,CDC,2000. 2. CDC. Preventing Smoking and Exposure to Secondhand Smoke Before, During, and After Pregnancy, 2007


Smoking and Education

• 27% of women with 9-11 years of education smoke during pregnancy compared to 2% of women with some college education

• 42.7% of non-Hispanic white women with 9-11 yrs of education smoke during pregnancy

Source: Martin JA, Hamilton BE, et. al. ―Births: Final data for 2002. National vital statistics report: vol.

52, no. 10, National Center for Health Statistics. 2003


Pregnancy and Smoking - Risks

• Pregnant smokers are 1.5 to 3.5 times more

likely to have a low birth weight baby • Almost ¼ of all SIDS deaths have been

attributed to prenatal maternal smoking • Fetal Mortality rates 35% higher among

pregnant women who smoke than nonsmokers

Source: Pollack,H, ―Sudden Infant Death Syndrome, Maternal Smoking During Pregnancy, and the Cost-Effectivesness of Smoking Cessation Intervention,: American Journal of Public Health (91(3):432-36, March 2001


Effects on Children

• Parents who smoke have children who are more vulnerable to: • respiratory illnesses • middle ear infections • impaired lung function • behavioral and developmental problems

• Parental smoking estimated to cause direct medical expenditures

of >$4.5 billion per year for smoking-caused problems in infants and children as well as to treat pregnancy/birth complications

Source: Hu. FB et al., Prevalence of asthma and wheezing in public schoolchildren: association with

maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1):0-84.July 1997

Aligne. CAA, Stoddard JJ. ‖Tobacco and Children: An Economic Evaluation of the Medical Effects of Parental Smoking‖, Archives of Pediatric and Adolescent Medicine.151:648-53.July 1997


Smoking Cessation Can Make a Difference

Quitting by the 1st trimester results in infant weight and body measurements comparable to infants of nonsmokers1

Quitting at any time is a health benefit to mom and baby

Source: US Dept Health and Human Services. Women and Smoking: a Report of the Surgeon General.2001


State Medicaid Coverage

2006 review by the CDC found: • 14 states provided tobacco cessation counseling

specifically for their pregnant women on Medicaid • 39 states covered some form of evidence-based

cessation counseling • 28 states covered at least one category of FDA-

approved cessation drug

―State Medicaid coverage for tobacco cessation and treatment is sporadic and, even if it is deemed ―comprehensive‖ it may not be tailored to address the unique needs of specific populations like pregnant women who smoke‖

Source: CDC, State Medicaid Coverage for Tobacco-Dependence Treatments –United States, 2006, MMWR57(05):117-122, February 8, 2008.


Puff Free Pregnancy

A Unique Approach

• Researched current available programs & best practices

• Involve OB providers

• Enlist health plan care managers for additional support

• Provide tool kit to support cessation

• Identify and break down barriers

• Provide non-judgmental one-on-one support

• Allow unlimited calls with health coach


Capitalize on a Teachable Moment

• Educate member on negative health effects of smoking during pregnancy

• Acknowledge barriers such as stress, mental health issues, economic situation

• Empower member to help improve the health of her baby

• Assist member to avoid second hand smoke

• Impress health benefits of smoke free environment for infants & children


Program Design

• Program is based on clinical guidelines published by The American Congress of Obstetricians and Gynecologists (ACOG) and US Public Health Service

• Nurtur Coaches are Certified Tobacco Treatment Specialists with additional training on counseling on cessation during pregnancy

• Coordination with provider to inform when their patient has joined, when we’ve lost contact and when the member has completed the program


Program Design

The Program incorporates:

• An individualized cessation plan

• Quit date preparation

• Identification of tobacco cues and coping strategies

• Stress Management techniques

• Relapse Prevention

• Tool kit w/ educational materials with appropriate health literacy (4-5th grade)


Program Specifics • Medical Providers identify pregnant smokers to health plan

with the Notification of Pregnancy Form

• Outbound calls made to explain program and enroll member

• Members who are ready to make a quit attempt and are <34 weeks are eligible to enroll

• Follow up call to document tobacco status within a month after delivery

• If unable to reach or member declines, a letter and cessation materials are sent


Current Status

• Currently 5 Medicaid health plans

• Total enrolled to date: 680 (consented to program)

• 331 completed the program (48%)

• 349 lost to follow up (51%)

• 22% quit rate (of all enrollees, including those lost to follow up)

• 25% cut back on amount of smoking (of all enrollees, including those lost to follow up)


Puff Free Pregnancy Prescription


Nurtur Health Coach

Toolkit

• Educational booklet

• Baby bib and bottle

• Toothbrush

• Book

• Stress ball

• Magnet

• Mints


Outcomes

• Focus on our Ohio Medicaid Health Plan

• Review of 226 participants (Jan ’07 to Dec ’09)

• 135 (59.7%) completed program

• Quit rate 29.6%, self reported

• Benchmark is 13.3%1

• Non-quitters reduced daily use by 54% from 13 per day at start of program to 6 per day at program completion

Source: Fiore MC, Jaén CR, Baker TB, et al (2008). Clinical practice guideline: treating tobacco use and

dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf.

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf




Methodology

Propensity Score Matching for Control Group • Employs a predicted probability of group membership—e.g.,

participant vs. identified non-participant—based on observed predictors, obtained from logistic regression to create a counterfactual group.

• Uses a composite variable—e.g., a propensity score—that minimizes group differences

• Used to minimize selection bias

• Hidden bias may remain because matching only controls for observed variables (to the extent they are perfectly measured).

• ―Nearest Neighbor matching‖: Randomly order the participants and non-participants and find the non-participant with the closest propensity score.


Maternity-Related Hospitalizations Were Lower

1,095.9

1,615.0

0.0

200.0

400.0

600.0

800.0

1,000.0

1,200.0

1,400.0

1,600.0

1,800.0

Maternity-Related Hospitalizations 1,000

member-years

Participant Non-

Participant

Measure is statistically significant (p=0.001)

32.1% difference


Length of Hospitalization Stay Was Lower

3.2

4.9

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Average length of stay for maternity-related

admission

Participant Non-

Participant


34.7% difference


Maternity-Related Visits to Physician Offices Were Higher

11.5

8.5

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Maternity-related visits to physician office

per claimant year

Participant Non-

Participant


35.3% difference


Visits to Physician Offices Were Higher

8.4

7.1

6.0

6.5

7.0

7.5

8.0

8.5

Visits to physician officer per claimant year

Participant Non-

Participant


18.3% difference


Several Other Measures Show Improvement

1,207.5

1,733.1

0.0200.0400.0600.0800.0

1,000.0

1,200.01,400.01,600.01,800.02,000.0

Non-maternity admissions per 1,000

claimant-years

30.3% difference

1,566.3

2,214.6

0.0

500.0

1,000.0

1,500.0

2,000.0

2,500.0

NICU admissions per 1,000 claimant-

years

29.3% difference

557.1

717.8

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

800.0

Premature and other low birth weight

deliveries per 1,000 claimant-years

22.4% difference

53.7

52.1

51.0

51.5

52.0

52.5

53.0

53.5

54.0

Influenza Vaccination rate per 1,000

claimant-years

3.1% difference

Participant Non-

Participant

Participant Non-

Participant

Participant Non-

Participant

Participant Non-

Participant


Future Steps

• Improve on early identification of those who could benefit

– predictive modeling software

– Provider outreach

• Prioritize those with co-morbid conditions such as asthma or history of preterm delivery

• Improve ability to find our members (email, social networking, texting)

• Follow outcomes of babies through first year of life to demonstrate cost-effectiveness

• Increase preventive care

– Flu shots, mammograms, dental


Summary

• Comprehensive multi-tiered approach to smoking cessation

in this population is necessary

• A tough time to quit! Multiple barriers to success

• Early outcomes suggest trend toward having quit rate comparable to or better than other non-pharmacological programs

• Improved health outcomes of participants and babies can lead to healthier families


Questions

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