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Maternal Child E-Health Project

Project Goals. To create a ?Medical Home" for pregnant patients of the Health Center. As defined as providing care that is continuous, comprehensive, coordinated, and compassionate. Helping patients to eliminate or reduce barriers to receiving health care. . Project Description. Serve as ?Medical Ho

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Maternal Child E-Health Project

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    1. Maternal Child E-Health Project Greater New Bedford Community Health Center, Inc.

    2. Project Goals To create a “Medical Home” for pregnant patients of the Health Center. As defined as providing care that is continuous, comprehensive, coordinated, and compassionate. Helping patients to eliminate or reduce barriers to receiving health care.

    3. Project Description Serve as “Medical Home” to all women presenting to the Health Center with positive pregnancy tests Implement an integrated practice management system and e-health record system to facilitate the coordination and tracking of the health care of the target population

    4. Target Population All women and adolescents who received positive pregnancy tests at the health Center between September 1, 2007 through March 31, 2008 Total project participants 335

    5. Objectives Train staff on new practice management system Develop protocols for ensuring timely care of project participants Create Intervention (Nsg) plans for all participants continuing their pregnancies Create health maintenance alerts within EMR for patients with chronic health problems Create reports via EMR to track patients attendance to appointments Review monthly retention rates and need for system improvements with staff monthly

    6. Project Assets Commitment of Health Center at large to goals of Maternal Child Health (MCH) and of project Pre-existing work flow systems within MCH to promote early entry into prenatal care and other health care services Highly experienced, knowledgeable and compassionate staff

    7. Project Barriers Patient tracking demands of this project far exceeded the data collection and reporting capabilities of MSI practice management system The purchase and implementation of an EMR has been delayed beyond the project period

    8. Project Activities All MCH were trained in the new MSI (PMS) Including appointment/referral scheduling and data entry. All MCH staff trained in PECS reporting system Individual intervention plans were created for all MCH patients Pre-existing peri-natal protocols strengthened Manual collection of data completed

    9. Data Collection All data tabulated manually Quantitative data assessed for all participants included: Insurance status at time of positive pregnancy test Primary Language/other barriers to care Enrollment in primary care Smoking Status Substance use

    10. Data Collection (continued) Quantitative Data evaluated for participants continuing their pregnancies Trimester entered into prenatal care Chronic medical conditions Enrollment in Dental Care Referrals to outside agencies Birth outcome

    11. Data Collection (continued) Quantitative data evaluated for participants who have either chosen to terminate their pregnancies or had a miscarriage Age (assistance with court consent) Attendance to post TAB/SAB exam Initiation of birth control method

    12. Pregnancy Outcomes 335 positive pregnancies during project period 276 continued pregnancies 51 TABs 8 SABs

    13. Data Related to Participants Electing TABs or had SABs 29% were teens 2 of 2 teens requiring court consent, received assistance in doing so 32% were non-English speaking 19 of 19 non-English patients received case management services by staff whose primary language was their own

    14. TAB/SAB Data (Continued) 50/59 patients were scheduled for a post exam (85%) 45/59 attended (76%) 9/59 were lost to follow-up (15%) 45/45 participants who attended a post exam initiated a method of birth control (100%) Benchmarks???

    15. Pregnancy Related Data 276/335 chose to continue their pregnancies 79/276 were non-English speaking (30%) 72/79 received case management services by MCH staff who spoke their primary language (91%) 45/45 patients without health insurance at time of pregnancy test were assisted in obtaining insurance

    16. Pregnancy Related Data (Cont.) 70/276 were teens (25%) 57/70 were referred to Healthy Families program (82%) 128/276 participants had previous PCP 138/276 were assisted in obtaining PCP (50%) 2 declined, 8 unknown 155/276 were referred for Dental care (56%) 31/276 had dentist, 5 declined, 71/276 dental care not addressed

    17. Entry Into Prenatal Care

    18. Tobacco Use 69/276 participants smoked at time of pregnancy test (25%) 62/69 received documented brief intervention (91%) 52% either quit on own or were referred for further smoking cessation assistance Benchmarks??

    19. Tobacco use

    20. Medical Conditions The majority of participants did not have a pre-existing medical condition 167/276 (61%) Mental Health Issues were the most common chronic health concern 27% had prior diagnosis of either depression/anxiety/bi-polar or PTSD Obesity was the second most common chronic health condition at 17% Asthma was the 3rd most common at 6%

    21. Entrance into Prenatal Care 219 participants entered into prenatal in the first trimester 80% 29 entered into care in the second trimester 4 entered into care in the third trimester 24 unknown Benchmark: Adequate prenatal care in NB is 76%

    22. MCH Utilization 335 patients were referred to MCH in project period 304 patients received case management services (91%) 63 declined further MCH Services 101 followed via MCH home visiting 77 attending or scheduled to attend Health Center prenatal classes 57 Referred to outside agencies 31 lost follow-up

    23. Birth Outcomes 7 deliveries project period 0 low birth weight infants 1 adoption

    24. Lessons Learned Successes Individualized approach to care (Intervention plans) Addressing barriers to care Enrollment into primary care Addressing/Intervening high risk behaviors Adequacy prenatal care Pregnancy Outcome

    25. Lessons Learned Challenges No EMR No means of real-time data collection No means of capturing data over time or tracking individual patients over time No means of tracking patients once referred outside Health Center

    26. Next Steps With the implementation of an EMR that communicates with outside referral sources the Maternal Child E-Health Project is very promising As certainly improving the tracking method for appointments and procedures for prenatal care will lead to improved continuity and adequacy of prenatal care among the Health Center’s pregnant population

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