La Red Health Center Prenatal Services Program

Promotora Program evaluation was been initiated through the use of forms, tools, and defined daily work processes. Communication has been maintained with Ms. Angela Mora, a nationally renowned expert on promotora programs, who provided a feasibility assessment of community readiness for the implementation of the program, as well as on-going technical assistance and training for the promotoras. The Community Health Worker Evaluation Took Kit, developed by the University of Arizona, Border Vision Fronteriza Initiative, was utilized to evaluate program. The Took Kit provides twenty-one basic principles to guide the program, and step-by-step guidance and a selection of tools in conducting evaluation.

Clinical service delivery was held to the standards of care (American College of Obstetrics and Gynecology) and the clinical plan utilized by LRHC as a federally qualified health center. Care delivery was monitored through organizational quality improvement processes to assure that clinical standards of care were being met for prenatal care, diabetes screening and management, and HIV/AIDS screening, diagnosis, education, and referral, and overall women’s health. Patient satisfaction surveys were routinely administered to all new LRHC patients. Promotoras had copies of surveys available for patients and routinely elicited conversational feedback. Related to patient satisfaction, LRHC engaged in a patient redesign initiative aimed at increasing clinical efficiency and patient satisfaction.

LRHC, as a member partner of Delaware Health Net (DHN) (a former Bureau of Primary Health Care funded network), implemented a clinical tracking system (DocSite) to monitor clinical outcomes of all LRHC users. Various sort criteria can be utilized for the development of specific reports on prenatal patients. In addition, DHN developed in excess of 200 age and gender appropriate parameters for patient monitoring. Those focused on women of childbearing age were utilized by the SDHWFP as clinical checklists for thorough completion of all required counseling, testing, education, and referral services to be offered.

Last year DHN secured a federal HIT grant to implement electronic medical records at its partner member sites. A vendor has been selected and implementation has begun in two phases; the practice management system had a “go-live” date of June 2008 and EMR implementation has been scheduled for February 2009. Once fully implemented, the EMR platform will afford the Center a full array of enhanced clinical tracking and outcome reports.

Finally, as part of LRHC’s annual UDS and state reporting requirements, a tracking instrument has been developed to secure birth outcome statistics from local hospitals in order to better assess community impact.

During the three year grant period, the Center provided all or partial prenatal care to 1,134 pregnant women. Over this period, there was an increase of 76% in annual usership of the Center’s prenatal services: 288 the first year, 339 the second year, and 507 the third year.

Anecdotally, we have learned that the expansion of LRHC’s women’s health services have decreased the number of women who present to the local hospital emergency rooms for delivery without any prior prenatal care. This has been a major step in improving the overall birth outcomes and welfare of infants.

Despite our efforts and program successes to date, it remains a challenge to change established consumer behavior(s). Uninsured, low-income women tend to delay entry into prenatal care well into their third trimester. This occurs due to financial, transportation, and sometimes cultural reasons. Changing this behavior is a long-term, ongoing challenge that simply requires time. The following graph illustrates the first entry into prenatal care by trimester and depicts the chronic problem of late entry into care for our targeted population.

The Consortium will continue to seek and implement innovative strategies to improve early entry into prenatal care. Another area of potential concern is the continued growth of special populations in southern Delaware (and throughout the state). Not only does the gross population count continue to increase but so too does the proportion of those subpopulations which lack health insurance coverage. This combination of cultural and financial access issues is compounded by a general lack of obstetrical medical resources, particularly those that are culturally competent or affordable.

Since Delaware has one of the highest incidents of low-birth weights and infant mortality in the nation, there has been a great deal of focus on women’s health care during this project period. Due to the small size of the state of Delaware, Consortium members are engaged in a number of statewide health care initiatives which converge on many levels.

Currently there is movement afoot by the Delaware Health Care Commission to investigate opportunities for merging the Community Health Care Access Program (CHAP) which was a former federal CAP program, and the Delaware Infant Mortality initiatives administered by the Public Health Department. There have also been discussions with the Delaware Health Care Commission to act as a convener of a Sussex County Women’s Health Summit to develop and coordinate a countywide women’s health delivery system.

It has also been proven that community-driven health promotion programs are more effective than traditional programs. Community “buy-in” promotes ownership and ultimately leads to improvements in health status. Developing a consortium of agencies which can support the activities of the promotoras is an important component of a successful program as it will help to ensure coordination of, and provide training and support for, the promotoras.

The recruitment and training of the promotoras are critical elements in establishing an effective program. The promotoras must be natural leaders who are trusted by the community and skilled at listening and understanding the basic social and medical needs of individuals and their families. The promotoras must have full knowledge of the local programs which can help meet these needs and provide both linkages and follow-up to these services.

The Consortium has worked since onset to establish the program’s financial selfsufficiency/ sustainability. Case management services that are inherent to the program include aggressive financial screening for public coverage that results in Medicaid enrollments. As clients are enrolled in Medicaid and become established as users at LRHC, program generated income benefits substantially by its ability to bill on LRHC’s State negotiated cost-based reimbursement rate. All LRHC providers are enrolled as participating providers in the State’s Medicaid program. This too generates referrals of newly enrolled clients directly to LRHC as a facility.

During this grant period, LRHC also was designated as a Federally Qualified Health Center and began receiving federal funding in January 2006. Women’s health services are an integral component of both the Center’s business and clinical plans under this federal funding program.

There is considerably heightened State awareness on the issue of infant mortality. Health statistics from the Centers from Disease Control place Delaware as the one of the worst states in the nation in terms of infant mortality outcomes. As a result, State funds have been secured and are anticipated as a key source of continued revenue for the program. Additionally, since 2006 LRHC received State of Delaware/Title X Family Planning funds to complement and round out services to women.

AstraZeneca, as part of its Healthy Delaware Today and Tomorrow program has funded yet another patient navigator to assist in enrolling low-income individuals into public assistance programs. This has helped to augment enrollment activities conducted the onsite public eligibility worker and to streamline presumptive eligibility for Medicaid eligible women.

And finally, Ms. Dora Ward-Kyabu from the Georgia Health Policy Center conducted a technical assistance site visit focused on sustainability in March 2006. Ms. Ward worked with members of the Consortium to identify key sustainability issues for the prenatal program, but also for the combined access to care and services work, that the Consortium fosters. Subsequent to her visit, an LRHC case statement has been developed for use in ongoing fundraising of philanthropic funds to support the current operation and its longterm needs.

The CEO is now being called upon to present outcomes and impacts of the prenatal promotora program to forums throughout the state. LRHC and the Consortium are optimistic that this continued exposure of a best practice will help secure post-grant funding support.