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Organization and delivery of perinatal health care services at the community level
Organization and Delivery of Perinatal Health Care Services at the Community Level National Perinatal Information Center Providence, Rhode Island
University of South Florida School of Public Health Tampa, Florida
The document "Perinatal Health: Strategies for the 21st Century" was funded by the Maternal and Child Bureau, Department of Health and Human Services. The project served as a focal point for considering approaches to strengthening and improving the organization and delivery of perinatal health services. The National Perinatal Information Center and the University of South Florida School of Public Health worked in collaboration with a national advisory panel, which included representatives of perinatal health provider, education, and consumer groups to prepare the report. In the development of the strategies aimed at improving the system of perinatal health care in the United States, six substantive areas were addressed: comprehensive perinatal health care benefit package, financing, organizational structure, quality assurance, professional education, and perinatal health education. An iterative process involving focus groups and workshops was utilized to develop strategies. The strategic plan is based on the assessment that improving perinatal health must be accomplished through a broad-based effort focusing on changes in these areas: the structure and accountability of the perinatal organization and delivery system; access to comprehensive perinatal health services; financing; quality assurance; professional development; and patient/consumer education. These changes are aimed at the entire system rather than just the poor or medically indigent. The project, "Perinatal Health: Strategies for the 21st Century," has focused its efforts on delineating these changes, which, when implemented, will bring the nation toward an ideal perinatal health system for all women and their infants. We have excerpted one section of the plan, Organization and Delivery of Perinatal Health Care Services. Although we would recommend viewing the plan in its entirety, we see this section to be unique in its emphasis on the local delivery of care. As the debate over health reform heats up in Washington, policy planners lose sight of the fact that health care is fundamentally a community issue. The planning, implementation, and evaluation of perinatal services must be done on the local level. Editor's Note
T
his strategic plan for improving the organization and delivery of services is based on the recognition that services are ultimately delivered locally or regionally. Further, perinatal health care needs vary by geographic locale, contingent on such factors as availability of providers, facilities, and population characteristics. Therefore, c o m m u n i t y
WHI Vol. 3, No. 1 Spring 1993
Project Executive Committee David E. Gagnon, MPH Stanley N. Graven, MD George A. Little, MD Sister Jeanne Meurer, CNM, MS Rachel M. Schwartz, MPH Judy Sommers, MBA From "Perinatal Health Strategies for the 21st Century," a report funded in part by the Maternal and Child Health Bureau (HRSA) under a cooperative agreement with the National Perinatal Information Center in collaboration with the School of Public Health, University of South Florida.
COMMUNITY-LEVEL PERINATAL CARE 39
participation in and ownership of both the assessment of needs and development of plans for services are essential if universal access to comprehensive perinatal health is to be achieved. A guiding premise of this project has been the importance of enabling local communities to take responsibility for assuring availability and access to a full range of quality, population-based, risk and culturally appropriate perinatal health care services. The approach presented here for a community responsive delivery system is characterized by state, regional, and local flexibility in planning and implementation to meet the unique needs of their populations. An analysis of existing resources indicates that many key components of the service delivery system are already in place and operating effectively. This plan endorses development and strengthening of a public/private partnership among existing resources and cooperative, integrated planning efforts to create more comprehensive, population-based services. In addition to being community responsive, this approach emphasizes the importance of individual freedom in selecting health providers and in providing feedback to evaluate the effectiveness and sensitivity of services delivered. The approach presented here describes an accountability structure for the organization of perinatal health care services in the 21st century and delineates responsibilities at the community, state, and federal levels (both public and private). The intent of this approach is the organization of a delivery system which is mutually supportive among all levels. The discussion which follows highlights the interrelationships and activities at each level. The concept of community ownership and responsibility requires an identifiable entity to which accountability for perinatal health care access can be assigned. The term "community perinatal agency" (CPA) is used here to refer to an entity, which can be defined by political boundaries, market patterns, geographic size, and population density. It is the vehicle through which a public/private partnership can be built and/or enhanced. The structure and composition of the CPA would be tailored to the community and people to be served. For example, a CPA with responsibility for a rural, isolated area may be comprised of more than one county, whereas in a densely populated urban area, a CPA may be defined as one or more civic units. To the degree possible, a CPA would be built upon existing legal entities and infrastructure, such as city or county government. The partnership between the state and local community is based on empowerment of the CPA together with assignment of specific areas of responsibility to the state and CPA, respectively. The authority of the CPA would be derived from state legislation which establishes its legal status and delineates areas of accountability. These areas of responsibility and accountability assigned to the CPA are described below. Ultimate responsibility for universal access must be accepted by the community. This concept would form the basis of a contractual arrangement between the state and CPA which would make provision for the CPA's receipt of state support and other federal/state subsidies, contingent upon state approval of an annual community perinatal health care plan. Essential components of the community perinatal health care plan would include: • Ongoing needs assessment • Scope of services (community and individual health services) Population-based goals and priorities • Availability of services • Access to services • Identification of essential hospital(s), either within or outside the community's geographic area • Referral and linkage mechanisms • Care coordination •
40
COMMUNITY-LEVEL PERINATAL CARE
WHI Vol. 3, No. I Spring 1993
• • • • • •
Outreach and case finding Professional development Quality assurance Public education and awareness Evaluation methodologies Budget
Based on evaluation of the annual perinatal health care plan, the CPA would develop and refine a community-based delivery system to assure universal access to comprehensive perinatal health care services. A key component of the community plan is the requirement of formalized and documented arrangements for linkages among a full spectrum of perinatal health care providers and services. While many communities are not able to support all of the nonambulatory or specialized care services, it is recommended that basic primary care services be made available locally. Linkage agreements would then be required between the primary care sites and providers of specialized care services. Especially in rural areas, the nearest accessible hospital may be located outside the CPA geographic territory. It is necessary that the perinatal plan identify hospitals with which to establish formal linkages in order to assure availability of comprehensive services (essential hospitals). In addition to documentation of an ongoing working relationship, linkage agreements would need to verify the ability to transfer patient record information and to establish communication channels for consultation and education. A review process would be established to determine the eligibility of providers to receive reimbursement for the provision of perinatal health care services through a centralized payment system referred to as the state perinatal financing plan (SPFP). Eligibility would be based on national professional standards, state credentialing requirements, and documentation of existing linkages with appropriate health care providers. A primary function of the CPA would be the review of provider eligibility to receive reimbursement for the provisions of services. The CPA would submit its recommendations on provider eligibility to the state health deparhnent. The state health department would have the final authority to approve or disapprove provider eligibility. The requirement of providers to obtain approval would help to ensure that individuals and families receive quality care and access to comprehensive perinatal health services. In many communities, the creation of CPAs would require funding from the state health department, derived from both federal and state subsidies, to provide needed staffing and to develop or expand local infrastructure. Communities would be encouraged to identify~ preexisting infrastructure in order to avoid duplication of efforts and to develop an integrated, cost-efficient organizational structure. The allocation of federal/state subsidies by the state health department will enable the CPA to have the needed financial autonomy to pursue its delegated responsibilities. The CPA would also take a proactive role in assuring the continuous availability of perinatal health services in areas where adequate population coverage is problematic. This role would include, but not be limited to: 1) contracting with providers for direct care services and managing these contracts, 2) recruiting additional perinatal health care providers, and 3) developing model service programs utilizing state approved subsidies to develop or enhance community health services infrastructure. Innovative methods of maximizing utilization of existing resources would be encouraged. The CPA would have flexibility in designing mechanisms for administrative management and/or management of direct care services. For example, communities may contract with private firms for administrative and financial management services. Likewise, the CPA may contract with health WHI Vol. 3, No. I Spring 1993
COMMUNITY-LEVEL
PERINATAL CARE
41
care providers (hospitals, clinics, public health units, provider groups) to provide both administrative and financial oversight in addition to management of direct care services for a specific geographic territory. In addition, CPAs would play a role in establishing a more attractive environment within which providers can practice by arranging continuing education programs, arranging for coverage during leave, and establishing research and training linkages between providers, universities, and tertiary perinatal centers. Even when services are available, one difficulty in obtaining utilization of perinatal services has been identifying individuals who may not independently seek care. The CPA would be responsible for employing or contracting for outreach workers to reach individuals who have not sought perinatal care. Community services are an important component of comprehensive perinatal health care. The CPA would be responsible for facilitating community coordination and advocacy including efforts to develop needed community services, ie, social services, education programs, and family support services. Finally, the CPA would establish linkages with the elementary and secondary school systems aimed at integrating per~_natal health education into the schools. COMMUNITY BOARDS In addition to empowering the CPA, state legislation would also formally recognize the legal authority and responsibility of community boards. The effectiveness of the CPA is greatly facilitated by the creation of a community board to advocate local ownership of and involvement in the perinatal health issues of the community. The board would represent an opportunity to develop broad-based support by promoting membership of local public and private agencies and organizations, local health depai h~'~ents, community health centers, health care professionals, representatives of hospitals and clinics, civic government leaders, business and other community leaders, local school system representatives, consumers, and other perinatal interest groups. Board membership would reflect specific representation mandated by state law as well as appointments made by the CPA. The CPA would be required to obtain board approval related to community needs assessment, development, and implementation of an annual community perinatal health care plan and development of an annual budget. The board would also review and make recommendations to the CPA regarding the eligibility of providers to receive reimbursement for service provision through the SPFP. Finally, a quality assurance committee would be created as a subcommittee of the community board.
42
COMMUNITY-LEVEL PERINATAL CARE
WHI VoL 3, No. 1 Spring 1993
University of South Florida School of Public Health Tampa, Florida
The document "Perinatal Health: Strategies for the 21st Century" was funded by the Maternal and Child Bureau, Department of Health and Human Services. The project served as a focal point for considering approaches to strengthening and improving the organization and delivery of perinatal health services. The National Perinatal Information Center and the University of South Florida School of Public Health worked in collaboration with a national advisory panel, which included representatives of perinatal health provider, education, and consumer groups to prepare the report. In the development of the strategies aimed at improving the system of perinatal health care in the United States, six substantive areas were addressed: comprehensive perinatal health care benefit package, financing, organizational structure, quality assurance, professional education, and perinatal health education. An iterative process involving focus groups and workshops was utilized to develop strategies. The strategic plan is based on the assessment that improving perinatal health must be accomplished through a broad-based effort focusing on changes in these areas: the structure and accountability of the perinatal organization and delivery system; access to comprehensive perinatal health services; financing; quality assurance; professional development; and patient/consumer education. These changes are aimed at the entire system rather than just the poor or medically indigent. The project, "Perinatal Health: Strategies for the 21st Century," has focused its efforts on delineating these changes, which, when implemented, will bring the nation toward an ideal perinatal health system for all women and their infants. We have excerpted one section of the plan, Organization and Delivery of Perinatal Health Care Services. Although we would recommend viewing the plan in its entirety, we see this section to be unique in its emphasis on the local delivery of care. As the debate over health reform heats up in Washington, policy planners lose sight of the fact that health care is fundamentally a community issue. The planning, implementation, and evaluation of perinatal services must be done on the local level. Editor's Note
T
his strategic plan for improving the organization and delivery of services is based on the recognition that services are ultimately delivered locally or regionally. Further, perinatal health care needs vary by geographic locale, contingent on such factors as availability of providers, facilities, and population characteristics. Therefore, c o m m u n i t y
WHI Vol. 3, No. 1 Spring 1993
Project Executive Committee David E. Gagnon, MPH Stanley N. Graven, MD George A. Little, MD Sister Jeanne Meurer, CNM, MS Rachel M. Schwartz, MPH Judy Sommers, MBA From "Perinatal Health Strategies for the 21st Century," a report funded in part by the Maternal and Child Health Bureau (HRSA) under a cooperative agreement with the National Perinatal Information Center in collaboration with the School of Public Health, University of South Florida.
COMMUNITY-LEVEL PERINATAL CARE 39
participation in and ownership of both the assessment of needs and development of plans for services are essential if universal access to comprehensive perinatal health is to be achieved. A guiding premise of this project has been the importance of enabling local communities to take responsibility for assuring availability and access to a full range of quality, population-based, risk and culturally appropriate perinatal health care services. The approach presented here for a community responsive delivery system is characterized by state, regional, and local flexibility in planning and implementation to meet the unique needs of their populations. An analysis of existing resources indicates that many key components of the service delivery system are already in place and operating effectively. This plan endorses development and strengthening of a public/private partnership among existing resources and cooperative, integrated planning efforts to create more comprehensive, population-based services. In addition to being community responsive, this approach emphasizes the importance of individual freedom in selecting health providers and in providing feedback to evaluate the effectiveness and sensitivity of services delivered. The approach presented here describes an accountability structure for the organization of perinatal health care services in the 21st century and delineates responsibilities at the community, state, and federal levels (both public and private). The intent of this approach is the organization of a delivery system which is mutually supportive among all levels. The discussion which follows highlights the interrelationships and activities at each level. The concept of community ownership and responsibility requires an identifiable entity to which accountability for perinatal health care access can be assigned. The term "community perinatal agency" (CPA) is used here to refer to an entity, which can be defined by political boundaries, market patterns, geographic size, and population density. It is the vehicle through which a public/private partnership can be built and/or enhanced. The structure and composition of the CPA would be tailored to the community and people to be served. For example, a CPA with responsibility for a rural, isolated area may be comprised of more than one county, whereas in a densely populated urban area, a CPA may be defined as one or more civic units. To the degree possible, a CPA would be built upon existing legal entities and infrastructure, such as city or county government. The partnership between the state and local community is based on empowerment of the CPA together with assignment of specific areas of responsibility to the state and CPA, respectively. The authority of the CPA would be derived from state legislation which establishes its legal status and delineates areas of accountability. These areas of responsibility and accountability assigned to the CPA are described below. Ultimate responsibility for universal access must be accepted by the community. This concept would form the basis of a contractual arrangement between the state and CPA which would make provision for the CPA's receipt of state support and other federal/state subsidies, contingent upon state approval of an annual community perinatal health care plan. Essential components of the community perinatal health care plan would include: • Ongoing needs assessment • Scope of services (community and individual health services) Population-based goals and priorities • Availability of services • Access to services • Identification of essential hospital(s), either within or outside the community's geographic area • Referral and linkage mechanisms • Care coordination •
40
COMMUNITY-LEVEL PERINATAL CARE
WHI Vol. 3, No. I Spring 1993
• • • • • •
Outreach and case finding Professional development Quality assurance Public education and awareness Evaluation methodologies Budget
Based on evaluation of the annual perinatal health care plan, the CPA would develop and refine a community-based delivery system to assure universal access to comprehensive perinatal health care services. A key component of the community plan is the requirement of formalized and documented arrangements for linkages among a full spectrum of perinatal health care providers and services. While many communities are not able to support all of the nonambulatory or specialized care services, it is recommended that basic primary care services be made available locally. Linkage agreements would then be required between the primary care sites and providers of specialized care services. Especially in rural areas, the nearest accessible hospital may be located outside the CPA geographic territory. It is necessary that the perinatal plan identify hospitals with which to establish formal linkages in order to assure availability of comprehensive services (essential hospitals). In addition to documentation of an ongoing working relationship, linkage agreements would need to verify the ability to transfer patient record information and to establish communication channels for consultation and education. A review process would be established to determine the eligibility of providers to receive reimbursement for the provision of perinatal health care services through a centralized payment system referred to as the state perinatal financing plan (SPFP). Eligibility would be based on national professional standards, state credentialing requirements, and documentation of existing linkages with appropriate health care providers. A primary function of the CPA would be the review of provider eligibility to receive reimbursement for the provisions of services. The CPA would submit its recommendations on provider eligibility to the state health deparhnent. The state health department would have the final authority to approve or disapprove provider eligibility. The requirement of providers to obtain approval would help to ensure that individuals and families receive quality care and access to comprehensive perinatal health services. In many communities, the creation of CPAs would require funding from the state health department, derived from both federal and state subsidies, to provide needed staffing and to develop or expand local infrastructure. Communities would be encouraged to identify~ preexisting infrastructure in order to avoid duplication of efforts and to develop an integrated, cost-efficient organizational structure. The allocation of federal/state subsidies by the state health department will enable the CPA to have the needed financial autonomy to pursue its delegated responsibilities. The CPA would also take a proactive role in assuring the continuous availability of perinatal health services in areas where adequate population coverage is problematic. This role would include, but not be limited to: 1) contracting with providers for direct care services and managing these contracts, 2) recruiting additional perinatal health care providers, and 3) developing model service programs utilizing state approved subsidies to develop or enhance community health services infrastructure. Innovative methods of maximizing utilization of existing resources would be encouraged. The CPA would have flexibility in designing mechanisms for administrative management and/or management of direct care services. For example, communities may contract with private firms for administrative and financial management services. Likewise, the CPA may contract with health WHI Vol. 3, No. I Spring 1993
COMMUNITY-LEVEL
PERINATAL CARE
41
care providers (hospitals, clinics, public health units, provider groups) to provide both administrative and financial oversight in addition to management of direct care services for a specific geographic territory. In addition, CPAs would play a role in establishing a more attractive environment within which providers can practice by arranging continuing education programs, arranging for coverage during leave, and establishing research and training linkages between providers, universities, and tertiary perinatal centers. Even when services are available, one difficulty in obtaining utilization of perinatal services has been identifying individuals who may not independently seek care. The CPA would be responsible for employing or contracting for outreach workers to reach individuals who have not sought perinatal care. Community services are an important component of comprehensive perinatal health care. The CPA would be responsible for facilitating community coordination and advocacy including efforts to develop needed community services, ie, social services, education programs, and family support services. Finally, the CPA would establish linkages with the elementary and secondary school systems aimed at integrating per~_natal health education into the schools. COMMUNITY BOARDS In addition to empowering the CPA, state legislation would also formally recognize the legal authority and responsibility of community boards. The effectiveness of the CPA is greatly facilitated by the creation of a community board to advocate local ownership of and involvement in the perinatal health issues of the community. The board would represent an opportunity to develop broad-based support by promoting membership of local public and private agencies and organizations, local health depai h~'~ents, community health centers, health care professionals, representatives of hospitals and clinics, civic government leaders, business and other community leaders, local school system representatives, consumers, and other perinatal interest groups. Board membership would reflect specific representation mandated by state law as well as appointments made by the CPA. The CPA would be required to obtain board approval related to community needs assessment, development, and implementation of an annual community perinatal health care plan and development of an annual budget. The board would also review and make recommendations to the CPA regarding the eligibility of providers to receive reimbursement for service provision through the SPFP. Finally, a quality assurance committee would be created as a subcommittee of the community board.
42
COMMUNITY-LEVEL PERINATAL CARE
WHI VoL 3, No. 1 Spring 1993