Optimizing the Baltimore County Department of Health’s service referral process for pregnant women Emily Gruber, MPH/MBA candidate PHASE Practicum with Baltimore County Department of Health
Agenda 1. Introduction 2. Problem Statement 3. Methods 4. Results 5. Recommendation 6. Discussion 2
Bloomberg School of Public Health Infant mortality has decreased overall, but large JOHNS HOPKINS UNIVERSITY disparities persist Baltimore County – deaths per 1,000 live births Infant Mortality rates in Maryland by race/ethnicity Overall NH White NH Black Hispanic 16 Mortality rate per 1,000 live births 14 6.5 3.1 12.4 5.7 12 Risk factors for infant mortality: 10 • Maternal health factors 8 • Lack of appropriate prenatal care 6 • Failure to practice safe sleep behaviors • 4 Mental health conditions • Lack of paternal involvement 2 • No breastfeeding 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 These risk factors present opportunities for Year interventions to target at-risk mothers and prevent All race/ethnicity NH White NH Black Hispanic infant mortality Vital Statistics Administration. Maryland Vital Statistics, Infant Mortality in Maryland, 2017. Maryland Department of Health. 2017 3 Maryland Health Care Commission. Study of Mortality Rates of African American Infants and Infants in Rural Areas, Report to the Senate Finance Committee and the House Health and Government Operations Committee. November 2019. Shenassa E, Gleason J, De Silva D. Narrative Synthesis of Risk Factors for Infant Mortality Among African American and Rural Populations in the U.S. Family Science Department University of Maryland. May 2019.
Bloomberg School of Public Health Baltimore County Department of Health (BCDH) oversees three JOHNS HOPKINS UNIVERSITY maternal health programs Healthy Families America (HFA) More • External nonprofit; funded by HRSA Maternal, Infant, and intensive Early Childhood Home Visiting Program • Home visiting with standardized curriculum HFA PEP • Targets women with psychosocial risk factors • Pregnancy through age 5 Prenatal Enrichment Program (PEP) • Nurse home visiting, at least monthly External Internal • BCDH-funded • Targets women with medical risk factors BBH Babies Born Healthy (BBH) • July 2018, MDH grant-funded Less • Two zip codes: Cockeysville and Owings Mills intensive • Lighter-touch: care coordination and referrals 4
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Referral process for pregnant women ACCU – Administrative Care Coordination Unit – BCDH unit responsible for receiving referrals from people on Medical Assistance 5
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Problem Statement – BCDH is at risk of decreased enrollment in programs due to inefficiencies in the referral process Goal: Understand all facets of the referral process and provide recommendations for making the referral process more efficient and matched to patient need, ultimately leading to better maternal and infant health outcomes Methods 10 standardized interviews with BCDH stakeholders • Responsibilities of each unit • Views about current referral process • Recommendations for updated referral process flow 3 interviews with other Maryland county health departments • Understand what processes work elsewhere • Learn from their challenges Literature review • Benefits/risks of standardization of protocols in healthcare • Best practices for home visiting/care coordination programs for pregnant women 6
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Areas for improvement include: • Dual referrals to PEP and HFA • Poor electronic medical record documentation and reporting • Lack of communication between BCDH programs • Inadequate data forms used during referral • Insufficient community outreach and declining enrollment • Lack of standardized protocols within some programs • Clients receiving many separate phone calls 7
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Areas for improvement include: • Dual referrals to PEP and HFA • Poor electronic medical record documentation and reporting • Lack of communication between BCDH programs • Inadequate data forms used during referral • Insufficient community outreach and declining enrollment • Lack of standardized protocols within some programs • Clients receiving many separate phone calls 8
Bloomberg School of Public Health Clients receive many phone calls, which likely affects program JOHNS HOPKINS UNIVERSITY acceptance rates When pregnant women receive phone calls from many different people in BCDH throughout the referral process (in addition to calls from their OB or Managed Care Organization case manager), they become overwhelmed, confused, and may decline services. 9
Bloomberg School of Public Health Lack of communication can cause time delays and missing JOHNS HOPKINS UNIVERSITY information “As a health department program, we are all under the same umbrella. It would be very helpful if we knew what each other was doing, especially when clients are referred to multiple programs. There is some overlap and duplication of services.” 10
Bloomberg School of Public Health Non-optimized program assignment can direct women to a JOHNS HOPKINS UNIVERSITY program not best suited to her needs 1) Women with medical and psychosocial risk factors are dually referred to PEP and HFA. These women end up enrolling in the first program that approaches them, not the best fit 2) BBH receives referrals for all Owings Mills and Cockeysville women, even if they need more intensive services 11
Bloomberg School of Public Health Other counties have varied referral processes, with a JOHNS HOPKINS UNIVERSITY centralized intake point proving successful • Centralized referral point allows for referrals outside of ACCU • Possible referral sources: clinics, providers, self-referrals, word of mouth • Increased outreach to non-Medical Assistance populations • Standardized referral decision rules direct women to the best program for their needs 12
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Recommendations 1) Use standardized decision rules and protocols to streamline referral process flow and ensure high-quality services 2) Create structures for internal communication , including data sharing 3) Increase program outreach to the medical community and general public 13
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Lessons learned and practice implications 1) Importance of speaking with every stakeholder involved in a process 2) Difficulty of large organizational changes 3) Adapting best practices from one health department to another is important but difficult 4) Data can be a challenge at health departments 14
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Acknowledgements Baltimore County Department of Health Teresa Pfaff Dr. Teresa Messler Prenatal and Early Childhood Division PHASE Paulani Mui Beth Resnick April Tong Eril Smith Thank you to Teresa Pfaff and Teresa Messler for their support, guidance, and encouragement throughout this project. Thank you to Paulani, Beth, April, and Eril for your guidance throughout the PHASE program. 15
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Thank you! Questions? 16
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY References 1. Vital Statistics Administration. Maryland Vital Statistics, Infant Mortality in Maryland, 2017. Maryland Department of Health. 2017. https://health.maryland.gov/vsa/Documents/Reports%20and%20Data/Infant%20Mortality/Infant_Mortality_Report_2017 _20180919.pdf 2. Maryland Health Care Commission. Study of Mortality Rates of African American Infants and Infants in Rural Areas, Report to the Senate Finance Committee and the House Health and Government Operations Committee. November 2019. 3. Shenassa E, Gleason J, De Silva D. Narrative Synthesis of Risk Factors for Infant Mortality Among African American and Rural Populations in the U.S. Family Science Department University of Maryland. May 2019. https://mhcc.maryland.gov/mhcc/pages/home/workgroups/documents/african_american_study/AppC_RiskFactLitFINAL.p df 4. Korfmacher J, Laszewski A, Sparr M, Hammel J. Assessing home visiting program quality. Final report to the pew center on states. June 2012. 5. Nievar MA, Van Egeren LA, Pollard S. A meta-analysis of home visiting programs: Moderators of improvements in maternal behavior. Infant Ment Health J. 2010;31(5):499-520. Accessed Mar 3, 2020. doi: 10.1002/imhj.20269. 6. Cain KL, Collins RP. Using quality improvement to improve internal and external coordination and referrals. J Public Health Manag Pract. 2018;24 Suppl 3:S69-S71. Accessed Mar 3, 2020. doi: 10.1097/PHH.0000000000000722. 7. Toussaint J, Correia K. Why process is US healthcare's biggest problem. Harvard Business Review. 2018. 17
Bloomberg School of Public Health JOHNS HOPKINS UNIVERSITY Results: key literature • Effective home visiting programs for mothers and children: • Well trained staff • Standardized and comprehensive curriculum • More frequent visits are more effective • Consistent evaluation of outcomes • Standardized protocols in healthcare (such as referral decisions) lead to more error-proof and higher quality care 18
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