January 2004

Grant Results

National Program

Reach Out: Physicians' Initiative to Expand Care to Underserved Americans

SUMMARY

From 1994 to 1998, staff with the Gift of Life Foundation, a nonprofit community-based organization of the Montgomery, Ala. area, worked to remove barriers to care for infants born to low-income mothers in Montgomery's four-county region and to help prevent babies from "falling through the cracks" of the health care system there.

The project, called the Child Health Access Project, brought two new elements to an existing community-based effort of the Gift of Life Foundation:

  • A computerized tracking system for babies born under Gift of Life (comprising virtually all babies born to the area's low-income mothers).
  • Pediatric care coordination services.

The project was part of the Robert Wood Johnson Foundation (RWJF) Reach Out: Physicians' Initiative to Expand Care to Underserved Americans national program.

Key Results

  • Over the four-year RWJF funding period, the Child Health Access Project enrolled 3,627 babies who received regular pediatric care from 14 physicians newly recruited to the project.
  • By mid-1998, there were 2,805 babies ages zero to three receiving pediatric care — representing 80 percent of all babies born in the area to low-income area mothers.
  • At that point in time, 65 percent of project children two years of age or older had received six or more well-child visits and 91 percent were current with their immunizations.
  • Seventy-five percent of new mothers designated "high risk" because of family stress factors kept scheduled immunization appointments under the project, and 90 percent kept their newborn checkup appointments.

Funding
RWJF supported this project through two grants, for planning and implementation, totaling $294,858.

 See Grant Detail & Contact Information
 Back to the Table of Contents


THE PROBLEM

A 1987 report by the U.S. Department of Health and Human Services declared the four county region of Autauga, Elmore, Lowndes and Montgomery County, Ala., as one of the worst areas in the United States to have a baby. The area had extremely high rates of infant mortality, high rates of low-birthweight babies and high numbers of "walk-in" deliveries, with little or no systematic prenatal care. The available perinatal care for infants and mothers was uncoordinated, and underutilized.

In 1988, a coalition of private obstetricians, pediatricians, local hospitals, concerned community leaders and state and local governments established the nonprofit Gift of Life Foundation in Montgomery, Ala. With federal grant dollars and funds from community organizations as seed money, it established the Gift of Life project, an ongoing contract for the provision of obstetrical and nurse-midwifery services to medically indigent women qualifying for Medicaid, throughout Montgomery's four-county area. Prenatal care and delivery services were provided by contract with private physicians, obstetricians and certified nurse-midwives. All four of the county health departments, and a community health center, functioned as sites for prenatal care and care coordination services. The comprehensive perinatal delivery system was the first of its kind in Alabama. The Gift of Life system has since served as a model of obstetrical service delivery in the state. As of 1994, there were 22 maternity waiver programs in the state modeled to varying degrees after Gift of Life.

In 1994, just prior to the start of the Reach Out project, approximately 1,450 babies were born to low-income women in Montgomery County, virtually all of them delivered at the obstetrical and nursery unit of a downtown hospital, the Montgomery Regional Medical Center, under contract with Gift of Life. Gift of Life provided new mothers at the hospital with information on enrolling the new babies in Medicaid and WIC (the federal Women's Infants' and Children's food supplement program) and arranged the first two newborn appointments and the mothers' postpartum visits, among other things. Available data, however, showed that 68 percent of these newborns did not receive all their recommended screenings and immunizations, and there was evidence suggesting that many of the children who did receive care did not have a medical home — that is, a single, consistent provider of health care with service available at all times and with hospital support.

Making matters worse, in 1994 there was limited private care available for low-income children in Montgomery County, and virtually none in surrounding counties. Although Montgomery County had 21 private pediatricians, only 5 percent accepted Medicaid-eligible children for comprehensive pediatric care. These physicians over the years had expressed a variety of concerns: the low reimbursement rates under Alabama's Medicaid provision; the burdensome claims filing system; the impact of a high rate of missed appointments and poor patient compliance with medical recommendations; and the potentially unmanageable ancillary problems of the Medicaid-eligible population. The county Health Department and a Federally Qualified Health Center provided limited preventive and sick-child services to low-income children, but neither the county health department nor the health center offered night or weekend call or hospital support.

 Back to the Table of Contents


THE PROJECT

The Child Health Access Project implemented two elements in the Montgomery region not already found with Gift of Life: a tracking system with "well-child" clinical data (covering checkups, screenings and immunizations) and "care coordination" information for babies born under the system, and care coordination services focused on removing barriers to care and preventing babies from "falling through the cracks" of the health care system. The project, through ongoing working relationships established under Gift of Life, linked physicians providing pediatric care, the Montgomery Regional Medical Center (where the babies were born) and the Montgomery County Health Department. Project social workers brought new mothers into the system, and area pediatricians were asked to see 10 or more children per month at their offices, under Medicaid reimbursement, for well-child care. Medicaid paid for needed drugs.

The project system was tested in Montgomery as a pilot in late 1994, and in mid-1995 it was implemented for all Gift of Life (i.e. Medicaid) births in the greater Montgomery area. By 1998, project staff consisted of four social workers/care coordinators, an administrative assistant and a Children's Health Access Project manager directing the activities of the social workers/care coordinators. Two Montgomery pediatricians shared duties as project directors (A.Z. Holloway, M.D. and Robert Beshear, M.D.), and an advisory committee (which was also a standing committee of the Gift of Life board of directors) provided project guidance. The Children's Health Access Project received additional funding from area and national sources. (For a complete list of these other supporters, see the Appendix.)

The Children's Health Access Project featured the following elements:

  • Tracking system and in-hospital enrollment. The project's tracking system followed individual children through the health care system from birth until age three. (At age three, Head Start was theoretically available to coordinate health care and support services for many of these children, although it had too few "slots" available. Recently, area county health departments began accepting at-risk children for targeted case management.) Mothers were introduced to the Children's Health Access Project before their baby's birth, through Gift of Life. The Gift of Life case manager assigned to each mother during her pregnancy "handed off" after the birth to the Children's Health Access Project manager based at Montgomery Regional Hospital, the site of all Gift of Life deliveries. This manager met with the mother in the hospital to enroll her baby, answer questions about the project and provide basic information on health care for children and on enrolling the child in Medicaid. At this meeting, the mother chose her child's pediatrician (with a backup choice), and the manager addressed any barriers the mother might face in accessing health care and scheduled the first two newborn appointments after the baby's hospital discharge — with the first to be within five to seven days of discharge. For tracking purposes, the manager created a computer file on the newborn and issued the mother a Children's Health Access Project identification card. A computer network linking Montgomery Regional Medical Center with the providers involved with the project carried the baby's "well-child" medical care record and care coordination notes and records.
  • Care coordination. Following the baby's hospital discharge, a Children's Health Access Project social worker/care coordinator tracked compliance with the newborn visits and maintained computer records of services received by the child. Future appointments were scheduled, the family was reminded of impending appointments and any barriers to compliance were addressed, including transportation and family stress issues. The tracking system tracked well-child screenings, immunizations, WIC participation and other information significant to the child's health care status. Significant psychosocial issues were referred to the Children's Health Access Project manager at the hospital, who relied in turn on a referral network of service providers, developed under Children's Health Access Project, to address family-based barriers to care. For children at high health or psychosocial risk, Children's Health Access Project mounted more intensive care coordination.
  • The pilot project. In the project's pilot phase, which corresponded in time roughly with the first of the two RWJF grants (August 1994 to August 1995), staff used a database application originally developed for immunization tracking by the Alabama Department of Public Health and modified by a programmer at the Centers for Disease Control and Prevention (CDC) in Atlanta at no charge. It allowed staff to track a group of 308 "Gift of Life babies" whose mothers chose a single Montgomery pediatric provider providing care under Medicaid. Tracking also included all infants in the Montgomery Regional Medical Center's newborn intensive care unit. Under the pilot, these babies' medical care and care-coordination services were tracked continuously. By the pilot's end, in mid-1995, staff found that approximately 85 percent of the infants were up-to-date on scheduled well-child checkups and immunizations. "Significant compliance problems" were noted for the families of 5 percent of babies.
  • Physician recruitment. Beginning in the spring of 1995, project staff began recruiting area pediatricians, who would agree to share information with care coordinators for Gift of Life babies under Medicaid reimbursement. Staff met with each pediatric provider, explaining recent changes in Medicaid (including increased reimbursement rates) and offered assistance in dealing with the state's Medicaid agency.
  • Full implementation. By the pilot's end, all babies born under Gift of Life (approximately 1,450 per year) were enrolled in the Children's Health Access Project. In late 1996, following consultations with RWJF's Reach Out national program staff, and in light of experience gained during the pilot phase, project staff refined their goals in five areas:
    1. Improve and enhance the system of care coordination for high-risk newborns.
    2. Establish a strategy to obtain permanent funding sources.
    3. Continue to recruit and enroll remaining private pediatricians into the Children's Health Access Project and increase the number of children with a medical home.
    4. Expand the tracking and care coordination system to one area community health clinic with a high volume of Gift of Life mothers.
    5. Develop a method to reduce the number of babies "bouncing" between pediatric providers. (Efforts to reduce "bouncing" met with limited success. Even mothers who routinely took their babies to only one provider for both sick and well-child visits, would take their baby to the county health department for immunizations.)

 Back to the Table of Contents


RESULTS

  • Between August 1994 and August 1998, staff recruited 14 physicians to provide pediatric care (total recruitment was 16, with two withdrawing). This exhausted the willing community pediatrician base as of mid-1998.
  • In this period the project enrolled 3,627 babies — 80 percent of all babies born through Gift of Life. Of these babies enrolled, 32 percent (1,161 babies) were dropped from the tracking system due to moving, obtaining private insurance, using a provider not enrolled in the project or otherwise being "lost" from the system (could no longer be located). The number of newborns enrolled with a participating pediatric provider averaged approximately 65 babies per month. At the end of the grant period (August 1998), 2,805 babies were enrolled.
  • As of mid-1998, 65 percent of project children two years of age or older had six or more well-child visits, and 91 percent were current with their immunizations. This reflected the work of three project social worker/care coordinators, each assigned to one or more participating pediatricians. Each tracked "well-child" and immunization encounters with Children's Health Access Project newborns at assigned provider sites. In the 12 months preceding August 1998, care coordinators recorded 4,878 encounters with the mothers of newborns. In 1996, project staff codified its extensive care coordination experience in a Care Coordinator Manual, used as a staff resource and tool. Eighty-one percent of new mothers responding to a questionnaire sent them after delivery reported that the social worker had referred them for help when needed, and 100 percent of new mothers reported use of at least one resource such as WIC or food stamps.
  • By the project's end 75 percent of mothers with infants designated by Children's Health Access Project as "high-risk" kept scheduled immunization appointments, and 90 percent kept their newborn checkup appointments. A "Child Health New Mother Program" established in 1996–1997 to help all newborns, but especially to better help high-risk newborns, helped achieve these results. Those infants designated as at high risk (using a family stress checklist) received a home visit within 10 days of discharge, follow-up services and focused care coordination. High-risk mothers received additional home visits by their care coordinator, tailored to the mother's specific needs and situation.
  • In August 1997 staff was able to place a care coordinator at the Montgomery Primary Care Center of the Montgomery County Health Department. Collaboration with this community health center was pivotal, since the center was the pediatric choice of a large portion of Gift of Life mothers. As of mid-1998, the project was tracking and providing care coordination services to 295 children and their families at this site.

Communications

Project staff held a news conference in August 1994 to announce the initial Reach Out grant, which resulted in local coverage by a number of TV newscasts and newspapers. The project received local and regional coverage throughout the RWJF funding period. A project co-director made presentations at the North Carolina/South Carolina Chapters of the American Academy of Pediatrics in 1995 and before the Pediatric Faculty and Residency Program at Children's Hospital in Birmingham, Ala., in 1996. Information on the Children's Health Access Project is available under "Child Health" at the Gift of Life Web site. For further communication details, see the Bibliography.

 Back to the Table of Contents


AFTER THE GRANT

The Children's Health Access Project (and the Gift of Life Project) continues to serve approximately 95 percent of low-income births in the greater Montgomery area. It now operates in two Montgomery hospitals and is negotiating participation with a third. In late 1998, the Alabama Medicaid Agency implemented a mandatory case management model, assigning a primary medical provider to each newborn who is responsible to coordinate the baby's care and maintain a unified patient record.

The system reduced some problems experienced by the project caused by new mothers "bouncing" from provider to provider. During 1998–1999, staff created three five-minute new mother education videos, produced with help from the Alabama Department of Public Health. These are shown to pregnant women in Gift of Life maternity clinic waiting rooms, Department of Public Health clinics and some doctors' offices.

As of 2002, the Children's Health Access Project continues to serve 1,200 to 1,400 patients per year, funded through United Way and with support from the Gift of Life budget. A funding request has been made to the Alabama Health Department.

 Back to the Table of Contents


GRANT DETAILS & CONTACT INFORMATION

Project

The Child Health Access Project

Grantee

Gift of Life Foundation (Montgomery,  AL)

  • Planning Grant
    Amount: $ 94,858
    Dates: August 1994 to July 1995
    ID#:  024551

  • Implementation Grant
    Amount: $ 200,000
    Dates: August 1995 to July 1998
    ID#:  027441

Contact

Martha Jinright
(334) 272-1820
golfound@aol.com

Web Site

http://www.golfound.com

 Back to the Table of Contents


APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Additional Funders of the Child Health Access Project

  • Montgomery-Autauga-Elmore [Counties] Medical Auxiliary ($20,200 in 1993–94)
  • Montgomery Area Community Foundation ($3,000 in 1993)
  • The American Academy of Pediatrics Community Access to Child Health program ($10,000 in 1994)
  • The Alabama Children's Trust Fund ($15,000 in 1995, 1996 and 1997, in support of the project's "New Mother Program" component)
  • In addition, the Gift of Life Foundation designated some funds for the project from its yearly operating budgets, and clinic and private providers donated space, phone lines and other in-kind contributions. The project's co-Directors, Albert Z. Holloway, M.D., and Robert Beshear, M.D., together donated in-kind time valued at an estimated $15,000 annually during the four-year RWJF-funded period.

 Back to the Table of Contents


BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Stiff J (ed.). Child Health Access Project — Care Coordinator Manual. Montgomery, Ala.: Gift of Life Foundation, 1996. Policy and procedures manual for all Child Health Access Project employees.

Audio-Visuals and Computer Software

Child Health Access Project — Educational Video, three five-minute segments on new-mother and infant health issues and on Child Health Access services, shown in maternity waiting rooms. Montgomery, Ala.: Gift of Life Foundation and Alabama Department of Public Health, 1998.

World Wide Web Sites

www.golfound.com offers a page on the Child Health Access project, listing pediatricians who participate, as well as financial supporters and a brief history of the project. Montgomery, Ala.: Gift of Life Foundation, 2001.

 Back to the Table of Contents


Report prepared by: James Wood
Reviewed by: Janet Heroux
Reviewed by: Marian Bass
Reviewed by: Molly McKaughan
Program Officer: Susan Hassmiller

Most Requested