Patient Navigator Program

State: WA Type: Model Practice Year: 2011

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"The Patient Navigator Program, called Pregnancy Partners, was implemented in September, 2009, and helps pregnant, low-income women access early prenatal care. Women in the program receive assistance in navigating the Medicaid system, completing a Medicaid application, selecting and applying for managed care, finding a provider, and receiving referrals to other services to overcome barriers such as transportation, childcare, and food assistance. Promoting the health and well being of pregnant women is a critical step for ensuring healthy, thriving children. Access to first trimester prenatal care is an important part of ensuring positive birth outcomes among infants. Late prenatal care is associated with costly negative health outcomes for mothers and infants as well as the health care system. Increasing rates of late prenatal care correlate with increasing rates of low birth weight babies, resulting in substantially higher costs of medical care and hospitalizations for low birth weight infants. In addition, late onset of prenatal care may result in delayed identification of maternal risk factors and treatment of conditions such as diabetes and high blood pressure, also leading to an increase in the cost of health care.

A Healthy People 2010 objective is that 90% of pregnant women receive prenatal care in their first trimester. A review of the Washington State Local Public Health Indicators in 2007 found a lower level of first trimester prenatal care in Clark County compared to Washington State and the national 2010 goal of 90%. Within Clark County there was a large disparity between the percent of non-Medicaid women and the percent of Medicaid women receiving first trimester prenatal care. This was especially apparent for women receiving Temporary Assistance for Needy Families (TANF). Women in Clark County Washington are receiving late prenatal care. In 2007, only 74% of Clark County women received first trimester prenatal care. In addition, the rate of first trimester prenatal care access was significantly lower among women on Medicaid, with just 58% receiving care compared to 85% of non-Medicaid, insured women. This is a 47% difference between Medicaid and non-Medicaid women.

When the data are delineated further, it is learned that even within Medicaid categories there are differences. Non-Citizen Medicaid-paid births had the lowest percent of first trimester prenatal care (47%), followed by women on Temporary Assistance for Needy Families (TANF) (57%), and finally Pregnancy Medical S-Program women (62%). Clark County Public Health (CCPH) began an effort within the community to improve first trimester prenatal care for women on Medicaid, with a focus on TANF women. The process was initiated by hosting two community forums and conducting focus groups that included clients, health care providers, and social service staff to identify some of the potential barriers for women. For clients, understanding the system, available resources for transportation and childcare, and feelings of discrimination were some of the greatest barriers they faced. For providers, staffing issues, low reimbursement, and the demands of high-need clients were major barriers. And for the Washington State Department of Social and Health Services (DSHS), staffing resources, the application process, and managed care complexities were identified as systems barriers. A Patient Navigator system was recommended as one method to address some of the issues raised. The primary goal of the Patient Navigator is to increase access to first trimester prenatal care for TANF/Medicaid women by 50%. To track and report the impact of the program, key performance measures were developed and data collection systems implemented. In addition, program success stories are collected and reported to meld the qualitative and quantitative outcomes of the program in a periodic report called a Performance Snapshot. Since implementation of the program, 58 women have participated in"

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Clark County Public Health
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Patient Navigator Program
"The Patient Navigator Program, called Pregnancy Partners, was implemented in September, 2009, and helps pregnant, low-income women access early prenatal care. Women in the program receive assistance in navigating the Medicaid system, completing a Medicaid application, selecting and applying for managed care, finding a provider, and receiving referrals to other services to overcome barriers such as transportation, childcare, and food assistance. Promoting the health and well being of pregnant women is a critical step for ensuring healthy, thriving children. Access to first trimester prenatal care is an important part of ensuring positive birth outcomes among infants. Late prenatal care is associated with costly negative health outcomes for mothers and infants as well as the health care system. Increasing rates of late prenatal care correlate with increasing rates of low birth weight babies, resulting in substantially higher costs of medical care and hospitalizations for low birth weight infants. In addition, late onset of prenatal care may result in delayed identification of maternal risk factors and treatment of conditions such as diabetes and high blood pressure, also leading to an increase in the cost of health care. A Healthy People 2010 objective is that 90% of pregnant women receive prenatal care in their first trimester. A review of the Washington State Local Public Health Indicators in 2007 found a lower level of first trimester prenatal care in Clark County compared to Washington State and the national 2010 goal of 90%. Within Clark County there was a large disparity between the percent of non-Medicaid women and the percent of Medicaid women receiving first trimester prenatal care. This was especially apparent for women receiving Temporary Assistance for Needy Families (TANF). Women in Clark County Washington are receiving late prenatal care. In 2007, only 74% of Clark County women received first trimester prenatal care. In addition, the rate of first trimester prenatal care access was significantly lower among women on Medicaid, with just 58% receiving care compared to 85% of non-Medicaid, insured women. This is a 47% difference between Medicaid and non-Medicaid women. When the data are delineated further, it is learned that even within Medicaid categories there are differences. Non-Citizen Medicaid-paid births had the lowest percent of first trimester prenatal care (47%), followed by women on Temporary Assistance for Needy Families (TANF) (57%), and finally Pregnancy Medical S-Program women (62%). Clark County Public Health (CCPH) began an effort within the community to improve first trimester prenatal care for women on Medicaid, with a focus on TANF women. The process was initiated by hosting two community forums and conducting focus groups that included clients, health care providers, and social service staff to identify some of the potential barriers for women. For clients, understanding the system, available resources for transportation and childcare, and feelings of discrimination were some of the greatest barriers they faced. For providers, staffing issues, low reimbursement, and the demands of high-need clients were major barriers. And for the Washington State Department of Social and Health Services (DSHS), staffing resources, the application process, and managed care complexities were identified as systems barriers. A Patient Navigator system was recommended as one method to address some of the issues raised. The primary goal of the Patient Navigator is to increase access to first trimester prenatal care for TANF/Medicaid women by 50%. To track and report the impact of the program, key performance measures were developed and data collection systems implemented. In addition, program success stories are collected and reported to meld the qualitative and quantitative outcomes of the program in a periodic report called a Performance Snapshot. Since implementation of the program, 58 women have participated in"
Prenatal care throughout pregnancy increases opportunities for improving the long-term health of mothers and their infants, thereby contributing to a healthier society and lower financial burden to families and taxpayers. This project addressed two important public health issues, healthy birth outcomes through assuring early entry into prenatal care and decreasing health disparities. Healthy Birth Outcomes Healthy People 2010 describes three major components of prenatal care that contribute to reduced illness, disability, or mortality. The components are risk assessment, treatment for medical conditions or risk reduction, and education. Prenatal care helps identify and potentially mitigate risk factors that could contribute to poor birth outcomes. Some common examples of risk factors during pregnancy are tobacco and alcohol use. Prenatal care is more likely to be effective if begun early in pregnancy. The percent of pregnant women receiving prenatal care in Clark County during their first trimester was statistically significantly lower than Washington State’s percent (74% versus 76%). More specifically, the percent of women enrolled on Medicaid receiving first trimester prenatal care was also statistically lower than Washington’s, 58% and 65%, respectively. Health Disparity In general, there is a gap between first trimester prenatal care between women enrolled in Medicaid and those who are not. In Clark County, a large disparity exists whereas non-Medicaid pregnant women access first trimester prenatal care 47% more often than Medicaid women (in 2007). This is considered a statistically significant difference. Of 2,315 Medicaid women with births in Clark County during 2007 for which trimester of prenatal care initiation was known, 970 women received prenatal care after the first trimester was over or did not receive prenatal care at all. Rates, in general, were worse for women receiving Temporary Assistance for Needy Families (TANF). Clark County Public Health began an effort within the community to improve first trimester prenatal care for women on Medicaid, with a focus on TANF women.
Agency Community RolesClark County Public Health (CCPH) first identified the issue of prenatal care entry after a review of the Washington State Local Public Health indicators in November 2007. Data showed a lower level of first trimester prenatal care in Clark County compared to the national 2010 goal of 90%. Additionally, there was a large disparity (47% difference) between the percent of non-Medicaid women and the percent of Medicaid women receiving first trimester prenatal care. CCPH first raised the awareness of the issue within the community to the local Board of Health. With Board of Health support, CCPH began an effort within the community to improve first trimester prenatal care for women on Medicaid, with a focus on TANF women. CCPH consolidated relevant data around prenatal care, hosted two community forums, and conducted focus groups that included clients, health care providers, and social service staff to identify some of the potential barriers for women. During the second community forum, CCPH proposed recommendations for strategies to improve first trimester prenatal care for women on Medicaid. These recommendations were derived from a combination of data from the previous forum, focus groups, and also research on the topic. The recommendations were accepted. With community support, CCPH convened workgroups comprised of staff and community members to focus on specific recommendations. These workgroups helped moved the recommendations forward into action. One workgroup was focused on the Patient Navigator system. CCPH secured funding from community partners to establish the Patient Navigator system within the department. By providing local data and evidence of community support, CCPH was also awarded an AmeriCorps position. Outcome data from the program helped secure a second year of funding and a renewal of the AmeriCorps position. ImplementationThe primary objective of the Patient Navigator system is to increase first trimester prenatal care among low-income pregnant women. The navigators assisted in developing the program, received training in related content areas of their work, studied community health data related to prenatal care trends of low-income women, and helped develop the pregnancy resource guide and referral information for Clark County. The first several months the navigators met staff in medical offices, social service agencies and pregnancy resource centers. They provided information about the new program including how referrals to navigators can be made. This was also a time of relationship building between the navigators and agency/clinic staff. The navigators attended WIC eligibility classes and other group opportunities to introduce themselves to low-income pregnant women. In addition to tracking our primary objective the navigators report key performance measures. Key Performance Measures: a. Percent of women referred to Pregnancy Partners during their first trimester of pregnancy b. Percent of women in Pregnancy Partners who receive first trimester prenatal care c. Percent of women referred that are enrolled in Medicaid through Pregnancy Partners Outreach is accomplished by developing and nurturing relationships with community partners who serve pregnant women and by working with faith-based organizations, WIC clinics and other group settings where low-income women may congregate and need pregnancy resources. In addition to traditional outreach, social media is used. The information is on our web site and messages are posted to our Facebook and Twitter accounts to encourage women to obtain early prenatal care and offer Pregnancy Partners as a resource to help women. The navigators work with women to address barriers, help them navigate the health care system, and link them to community resources and services. The navigator helps women complete the Medicaid application process, choose a managed care plan and obtain a prenatal care appointment. In addition they address other barriers including child care, transportation, food assistance, safe housing, and referrals for social services, mental health, and substance abuse treatment. The patient navigator also works closely with our public health nursing programs that include Nurse Family Partnership staff, nutritionists and social workers. This project began in November 2007 when the Washington State Department of Health’s Local Public Health Indicators were released to local health departments. In November, a senior manager and the epidemiologist explored the data to begin to understand the implications and discover the depth of the problem. The next step happened in December of 2007 when the problem was shared with our local Board of Health. Over the next year (2008) we embarked on the slow journey of working with community partners, holding focus groups, completing and analyzing surveys and disseminating findings among partners. The process described above also included generating solutions to consider. The second year (2009) was spent securing funding and implementing the recommendations such as developing the pregnancy resource guide and the Patient Navigator system. During the third year (2010), evaluations were conducted to report progress, identify needed modifications, and implement improvements where necessary. With the system now developed and operational, we are currently working to sustain efforts.
The primary objective of the Patient Navigator system is to increase first trimester prenatal care among low-income pregnant women (by addressing barriers, helping women navigate the health care system, and linking them to community resources and services). Key Performance Measures: a. Percent of women referred to Pregnancy Partners during their first trimester of pregnancy b. Percent of women in Pregnancy Partners who receive first trimester prenatal care c. Percent of women referred that are enrolled in Medicaid through Pregnancy Partners Data for all performance measures are taken from the Pregnancy Partners intake form.   The patient navigator collects the information directly from the women participating in the program either in person or on the telephone. Selected data elements are then abstracted from the intake form and entered in the program’s database. The specific data elements were the date of referral to the program, estimated due date, date of first prenatal care appointment, and whether the Medicaid enrollment was facilitated by the program. One initial finding dealt with the need for better data collection. In order to report out important aspects of the system (e.g. sources of referrals, referrals to agencies/organizations, applications for assistance, etc.) the intake form was revised to be able to better collect the needed information. Evaluation results were very positive for the program. Following program development and patient navigator training, 58 women participated in the program during the first year. Of women for which entry into prenatal care was known, 54% received first trimester prenatal care, and among TANF women, 75% did. Staff provided women with needed information, referrals, and community connections, including need-based assistance. Of the women staff were able to discuss referral options with, 96% received a referral(s) for community resources and/or services. In addition, staff also assisted women with applications for various types of need-based assistance. Of 58 women, 54 (93%) applied for pregnancy medical coverage, 12 (21%) applied for food assistance, and 9 (16%) applied for cash assistance through the state social services agency. This allowed women to have resources they needed and support beyond the traditional health care system. Overall, the Patient Navigator system was doing what it was designed to do – increase first trimester prenatal care among low-income women. The evaluation results were shared first and foremost with the stakeholders who had committed funding to the Patient Navigator system. Not only did this help secure commitments for a second year of funding, but the evaluation results were also used to approach additional community stakeholders for funding. Results have also been shared with the local Board of Health that continues to support the overall effort. Internally, results have helped modify the program as needed to best reach the goals. Modifications include contacting women to see that they were able to get in for their prenatal care appointment, reaching out to additional community sources that may be able to refer women to the program, and changing the data collection tool and process to better describe the program results.
The stakeholders involved are committed to improving birth outcomes and increasing access to first trimester prenatal care and will continue to work with public health to improve systems toward supporting healthy pregnancy outcomes. Benefits of the Patient Navigator system go well beyond helping the pregnant women access prenatal care. Assisting women in applying for Medicaid coverage and obtaining assignment in a managed care plan helps clinics and health care providers maximize reimbursement for pregnancy care. In addition the women receive early screening, pregnancy education and support services that increase the potential of healthy pregnancies and improve chances of healthy birth outcomes. The community partners are aware of these benefits to their practices as well as the community benefits gained by supporting healthy pregnancies and birth outcomes. Although funding the patient navigator positions is a challenge, the consortium approach to funding the positions helps spread the financial burden among Medicaid managed care plans, the hospitals and benefits health care providers serving the women. Transparency of funding allocations among the consortium partners and regular communication via our performance reports (Performance Snapshots) also help perpetuate support for the navigators. In addition to funds for the Patient Navigator system, the Department relies on partners to promote the navigators and help women connect with our services as early in the pregnancy as possible. Partners have added this resource to their portfolios shared with clients and also help distribute the pregnancy resource guides. Finally Clark County Public Health staff facilitate a community group – Community Health Access Resource Group (CHARG) – to promote networking among low-cost/no-cost health care providers and sharing of information, resources and new opportunities. This group not only receives information from public health staff but provides feedback to our staff for continuous improvement of all access to care services. In order to best ensure this program is sustained over time, Clark County Public Health plans to continue to engage elected officials, community partners and health care providers in the efforts. To expand the patient navigator practice, we received March of Dimes grant funding to develop a community-based navigator system by training locally recruited women as community patient navigators or pregnancy partners. This model will shift our program staff from direct service for women toward increasing capacity within neighborhoods and populations within the community to support pregnant women. We will work with local churches, ethnic-based organizations and non-profits to identify women interested in learning to be Pregnancy Partners and provide the training and support for their success. It is our belief that this will further increase sustainability as the support will become part of existing faith-based or community-based services. As we move in this direction we will continue to request funding from the consortium of funders as well as attract new clinics and health care organizations as program funders. In addition to maintaining and increasing the local funding consortium, we will continue to seek grant funds to further build capacity within in the communities across Clark County. The strong consortium of funders, the community coalitions and the relationships public health has in Clark County all contribute to increased probability of success and long term sustainability.
 
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