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UrduTopic: A health care system ( The Mount Sinai Hospital) and a Medicaid payer ( Healthfirst) partnered to develop an educational intervention and payment redesign program to improve timely postpartum visits for low-income high-risk mothers in New York City between April 2015 and October 2016.
Corresponding Author: Elizabeth A. Howell, MD, MPP, Director of the Blavatnik Family Women’s Health Research Institute, Mount Sinai Health System and Professor of Population Health and Policy and Professor of Obstetrics, Gynecology and Reproductive Medicine at the Icahn School of Medicine at Mount Sinai.
Results: An innovative partnership between a health care system and Medicaid payer improved access to health care services and community resources for high-risk postpartum mothers. The primary outcome was completion of the postpartum visit as defined by HEDIS (i.e. a visit with an obstetrics or primary care clinician between 21 and 56 days after delivery). The timely postpartum visit rate was higher for 363 mothers continuously enrolled in the program than for a control group matched by propensity score (67% [243/363] and 56% [407/726], respectively; P<.001). We used propensity score matching to compare timely postpartum visits for mothers enrolled in the program versus a similar group of mothers enrolled in the same Medicaid plan who gave birth in 2015 and 2016.
Why the Research Is Interesting: Many low-income women fail to get appropriate medical follow-up after delivery, putting their long-term health at risk. We evaluate a multifaceted program (behavioral educational intervention and payment redesign) designed to increase rates of timely postpartum visits according to Healthcare Effectiveness Data and Information Set (HEDIS) guidelines from the National Committee for Quality Assurance. Assessing postpartum care utilization of low-income, high-risk women with Medicaid coverage is challenging given plan enrollment and disenrollment patterns. A novel partnership between a health care system and a Medicaid payer increased postpartum visits among high-risk, low-income mothers. The follow-up rate was higher for visits that occurred within 90 days after delivery, a period consistent with current recommendations for postpartum care from the American College of Obstetricians and Gynecologists.
When: The program enrolled women insured by Healthfirst who delivered between August 2015 and October 2016 at The Mount Sinai Hospital, a large tertiary hospital in New York City.
What: An evidence-based behavioral intervention provided education about health conditions (hypertension, gestational diabetes, and depression), important health behaviors (nutrition and exercise), and common postpartum symptoms; taught self-management skills; enhanced social support; and connected patients with community resources and healthcare services. The intervention was implemented by a social worker and a community health worker in English and Spanish. Eligible participants included women aged 18 years and older who spoke Spanish or English and had at least 1 of the following: gestational diabetes, hypertension, positive screen for depression, late registration for prenatal care (>20 weeks), or residence in neighborhoods considered at high risk for diabetes or hypertension according to the New York City Department of Health and Mental Hygiene. A total of 217 women refused to participate, 3 withdrew from the program, and 3 were not found in the health insurance claims. Claims data were available for 506 enrolled mothers. The purpose of the program was to increase the number of low-income, high-risk women who have a timely postpartum care visit using a behavioral educational intervention and payment redesign. The payment reform component included a cost-sharing arrangement between the health care system and the Medicaid payer to cover costs related to employing the social worker and community health worker. Small financial incentives ($10) in the form of enhanced payments for completed postpartum visits by the payer were rolled out 12 months following the implementation of the intervention. Patients received round-trip public transportation and incentives ($10) gift card for attending their postpartum visit. Nonfinancial incentives included education for physicians, nurses, social workers, and registrars on the importance of the postpartum visit and on the clinical topics of gestational diabetes, hypertension, and postpartum depression.
Said Mount Sinai’s Dr. Elizabeth Howell of the research: “This is one of few initiatives that have integrated health care systems, payers, physicians and social workers to address access to care and social determinants of health for underserved women. The follow-up rate was higher for visits that occurred within 90 days after delivery, a period consistent with current recommendations for postpartum care from the American College of Obstetricians and Gynecologists. Our study adds important knowledge regarding the types of interventions that are needed by heath care systems and payers to increase access to maternal care for underserved women. Further, our program demonstrates the importance of including multiple stakeholders, patient education, care coordination, and community and medical resources to implement a successful new care model.
Funding: Support for this research was provided by the Robert Wood Johnson Foundation, Grant I.D. 72557 (EA Howell), “Reducing Disparities in Care for High-Risk Postpartum Women Through Redesign of Payment and Delivery Systems.” The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Robert Wood Johnson Foundation.
The Program for the Protection of Human Subjects (the institutional review board) at the Icahn School of Medicine at Mount Sinai approved this study under GCO#14-1033.
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