Pat Brannen, Hollard Phillips, Cindy Sowell, Marie Vickers
Southeast Health Unit, Waycross GA
Executive Summary | Definition
of Project | Industry Analysis | Target
Market
Marketing Strategy | Project
Operations and Management | Implementation Plan and
Timeline
Potential Risks and Regulatory Issues
| Financial Projections
Every time a preterm baby is born in South Georgia, weighing less than 1500 grams, it costs approximately $156,000 for the initial care of the infant. In the February 2, 2000 issue of the Journal of the American Medical Association, an article by Richard S. Strauss, M.D. describes the adult functional outcomes of low birthweight. This study implies a difference in academic achievement, professional attainment, and weekly income levels of adults who were low birthweight. The issues surrounding preterm births are complex. Financial experts struggle with the high costs of caring for an infant weighing less than 1500 grams. Social workers consistently identify the psychosocial stress that families endure when babies are born preterm. Historically, public health has faced many obstacles trying to reduce the number of preterm births by providing prenatal care and eliminating sexually transmitted diseases (STD) during pregnancy. However, the problem continues to plague communities. It is not the effort expended but the fragmentation of the programs that seems to be the problem. However, case management of women identified at greatest risk of preterm deliveries will not by itself minimize the immense burden facing families for whom prevention comes too late.
Family Links (FL), an intensive home visitation program, has been developed to respond to the medical needs of the families as well as to support them as they recover from the stresses of preterm delivery. The program will combine case management and nursing to provide home visiting services to families immediately after delivery until the infant reaches four years of age. Outreach, screening, assessment, goal setting, planning, implementation, and evaluation will be on going family/provider processes of Family Links.
Family Links' mission is to increase the capacity of families with preterm infants to manage, recover, and grow in their environment. Family Links is committed to building long-term relationships with families and healthcare providers in order to move families toward self-care, as well as to improve the systems which serve families. The program development goals are:
Specifically, Family Links will provide intensive home visiting services to families in the perinatal catchment area of Satilla Regional Medical Center (SRMC), a four county area of southeast Georgia. It will target pregnant women who deliver preterm.
Family Links is a public health program providing family-centered intensive case management to improve the outcomes and development of families who experienced preterm infant deliveries. Family Links' proactive approach versus a reactive, responsive one will set it apart from other efforts. As local public health initiative, Family Links' competitive edge in this field of service also includes community trust and expertise in population-based services and data collection.
Preventive healthcare services and programs are nationally recognized as a vehicle to move families toward optimal health. The founding organization, the Southeast Health Unit (SEHU), Georgia Public Health District 9-2, has a long-standing history of innovative, preventive health initiatives. No alternative market participants have yet emerged in the nurse-based intensive home visiting field in the state of Georgia. Nationally, other states have recognized and implemented home visitation models in an effort to reduce the fragmentation of services. Family Links plans to merge the following trends to model for the state a more comprehensive and effective system:
Family Links will be financed through existing funds in SEHU District programs. Revenues are available for the project to operate in a start-up status only. Diverse funding sources will be explored to sustain and expand the project on a long-term basis.
Nationally, a goal of Healthy People 2010 is to improve the health and well being of women, infants, children, and families. The Southeast Health Unit identified a critical need to address high rates of preterm delivery and associated health problems. The project name, Family Links, grew from SEHU's long history of collaboration with local and regional health care providers and the project's emphasis on families. The mission of this project is to increase the capacity of the family to manage, recover, and grow in their environment. The project goals will be achieved by the development of partnerships between the service delivery system and the family.
The program consists of a home visiting model with a clinical component designed to reduce the incidence of preterm deliveries (Appendix A). Preterm deliveries are devastating to the infant and the families, who must cope with the care of the child. There are socioeconomic factors associated with this diagnosis to be addressed as well.
The risk factors for preterm delivery are not perfectly understood, but bacterial vaginosis, family stress, substance abuse, educational levels, and prior preterm births have been implicated (Goldenberg, et.al, 1996). Through communication and collaboration with regional tertiary care facilities, recommended care will be obtained and other needs addressed. The RN's will work closely with the OB/GYN providers in monitoring and providing care for those women who have experienced a preterm birth. Intensive home visiting programs have been shown to effectively reduce poor outcomes by working with families prenatally and continuing through the early childhood years (The Packard Foundation Report, "The Future of Children"). The prevalence of risk indicators in families will determine the level and intensity of home visits by RN's. Caseloads will be limited for the sake of intensity and effectiveness in developing a trusting relationship.
Site visits by the Family Links team to existing programs in North Carolina provided opportunities to observe various home visitation models. Program manuals from home visitation models in North and South Carolina, Mississippi, Georgia, Florida, Louisiana, and New Mexico were extensively researched. Careful analysis of these programs resulted in the creation of a home visitation model with a nursing component in partnership with physicians and medical facilities that serve these families.
The goals of this project are:
The main differences between existing categorical programs and this project are:
Preventive healthcare services and programs are nationally recognized as a vehicle to move families toward optimal health. The Southeast Health Unit (SEHU), Georgia Public Health District 9-2, has a long-standing history of innovative, preventive health initiatives. No alternative market participants have yet emerged in the nurse-based intensive home visiting field in the state of Georgia. Nationally, other states have recognized and implemented home visitation models in an effort to reduce the fragmentation of services.
While the Southeast Health Unit has a long and proud history of making a difference in the health of the citizens of Georgia's Health District 9-2, providing public health services in this rural sixteen county area has not been an easy task. According to the 1998 Georgia County Guide, greater numbers of people living at or below poverty, fewer healthcare providers, and lack of a public transportation system are only a few of the factors negatively affecting the public's health in this region of Georgia. But innovative programs, strong collaborative efforts and a dedicated and well-trained work force have overcome many obstacles to better health care.
The Southeast Health Unit plays a vital role in the provision of health care. Over the past 25 years, the health departments have been partners with private physicians, local hospitals, and community organizations to improve the health of their communities. Historically, categorical programs have been developed to meet the needs of specific age groups. Although these programs have been successful in impacting the health of these various groups, gaps continue to exist.
Since 1974, under the leadership of Dr. Holloway, the infant mortality rate has declined from 15% to 9.3%. After assessing the characteristics of communities with high infant mortality rates, a plan was developed to address the issues district wide. Limited access, inadequate prenatal care and sexually transmitted diseases (STD) contributed to high infant mortality rates. The disparities of infant mortality rates between whites and minority groups gave rise to the formation of The Minority Health Task Force charged with "Bridging the Gap". Through collaboration with community leaders, organizations and agencies, this task force identified high-risk pregnant women and by case management ensured access to prenatal care, reduced STDs and improved pregnancy outcomes. The Minority Health Task Force led the efforts to impact the incidence of STDs. The incidence of syphilis cases dropped from 514 in 1991 to 65 in 1998.
During this effort other programs were shown to have a positive effect on prenatal outcomes. The number of participants enrolled in the Women, Infant and Children (WIC) program has increased by 28% since 1989. The improved nutritional status of pregnant women helped not just to improve the health of their babies and themselves but also provided opportunities for the public health nurses to assess the growth and development of the infants through programs such as EPSDT. Immunization rates climbed from 83% in 1990 to 97% in 1999 due to the initiative to use any clinic visit as an opportunity to assess immunization status. When Medicaid funding began to shrink and there were fewer clinic visits, SEHU partnered with private physicians to insure that immunization opportunities were not missed. Through a shared computerized patient information system, both public health and private physicians now track immunizations.
While the SEHU infant mortality rate decreased from 15 to 9.3 (per 1000 live births), there is still work to be done. In this health district, as in the state, very low birthweight babies (less than 1500 grams) account for only approximately 1.5% of all births but represent 53% of all infant deaths under 1 year of age. New challenges have emerged. Recent research has implicated STDs in preterm deliveries. The most prevalent STD among women is bacterial vaginosis (Center for Disease Control 1998 Sexually Transmitted Diseases Treatment Guideline) with an estimated 800,000 cases (Rosenberg, 1998). Threats to the newborn are many including stillbirth, low birth weight, neurologic damage and congenital abnormalities.
In the past, Medicaid reimbursement generated the largest portion of health department fees. However, since the implementation of Georgia Better Health Care, Georgia's Medicaid managed care plan, the health departments in the SEHU have experienced a decrease in Medicaid revenues. Developing strategic partnerships with SRMC, MHUMC, and other medical providers is essential for the financial and marketing success of Family Links.
The average cost of inpatient care for a premature infant in a neonatal intensive care unit in Georgia is $3,000 per day (Regional Perinatal Health Care Delivery System Assessment and Recommendations, August 1998). In 1998 in the SEHU, 65 preterm infants had birthweights of less than 1500 grams. Memorial Health University Medical Center, the regional neonatal tertiary care facility in Savannah, Georgia, reports an average stay of 52 days resulting in a cost of $156,000 for a preterm infant. As Family Links expands district wide, it projects a reduction of preterm deliveries by 10%, thus saving direct health care costs of $1,092,000. No attempt has been made to calculate the magnitude of the indirect costs of family disruption, suffering and emotional trauma.
The two key success factors of Family Links are:
Because existing health and family support services are categorical, there is no existing competition. However, competition for resources could develop due to the changing conditions and trends in health care. Potential competitors include:
Even though future competition could develop from the entities listed above, public health is the only agency that has a history and expertise in the areas of preventive health, population based services, and community based case management. The proposed approach will be more efficient and will involve cooperative work with these agencies. The primary barrier to success is professional and lay community buy-in. The danger is having Family Links viewed as another new program. By initiating this program in a four county area of the public health district, the most effective marketing strategies can be identified, implemented and validated.
The Southeast Health Unit is headquartered at 1101 Church Street, Waycross, Georgia. The health district encompasses 16 counties in southeast Georgia. This sprawling region covers a land area of 8,800 square miles, about the size of the state of Massachusetts, with a population of only 290,000. Vast stretches of this rural district are sparsely populated counties. Each of the 16 county health departments in the Southeast Health Unit has a nurse manager who oversees the operations of each site. Clinics are operated in compliance with federal and state regulations governing public health programs. The Georgia Board of Nursing licenses clinical staff. Federal, state, and local sources provide funding for the health departments. However, as these funds have essentially remained constant over the past six years, the costs of providing public health services have increased by 48%. In Medicaid programs such as Early Periodic Screening, Diagnosis and Treatment (EPSDT) revenues have decreased by 13%. The new leadership of the Department of Community Health has given the State a directive to reduce fragmentation of services and improve quality of care if Medicaid funding is to be continued (R. Toal, personal communication, Sept. 1999). Due to these budget constraints, the necessity of additional funding and innovative and efficient programs is critical.
Family Links will initially serve a four county area (Appendix B) targeting those families with highest risk of preterm deliveries. The counties include:
These counties, designated as medically underserved areas (HRSA, 1997), comprise the perinatal catchment area of Satilla Regional Medical Center located in Waycross, Georgia. The demographic characteristics listed below include socioeconomic factors of women at highest risk of preterm delivery.
| Brantley | Charlton | Pierce | Ware | |
| Square Miles | 444 | 780 | 343 | 902 |
| Population | 13,380 | 9,272 | 15,473 | 35,817 |
| General hospitals | 0 | 1 | 0 | 1 |
Source: Georgia County Guide, 1998
| Brantley | Charlton | Pierce | Ware | |
| % Below poverty | 19.6% | 21.3% | 21.1% | 22.6% |
| % Black population | 6.3% | 30.9% | 13.6% | 29% |
| % Hispanic population | .6% | .7% | 1.3% | .8% |
| % Single parent homes | 14.3% | 16.1% | 13.4% | 20.8% |
| School drop out rate (1997) | 10.1 | 9.9 | 10.8 | 5.5 |
| Low birthweight rate | 4.4 | 7.8 | 4.8 | 7.7 |
| # Physicians/1000 population | 0.8 | 0.2 | 0.4 | 1.6 |
Sources: HRSA, 1997, Vital Statistics, 1998, Kids Count, 1999
The project will target women at greatest perinatal risk. This targeted population includes:
The following performance measures will gauge the project's success for the targeted population:
Because the preterm birth event has consequences that touch many aspects of the maternal life course, the success measures are varied. Health experts recognize that if disparities between rural and urban, rich and poor, and white and minorities are to be eliminated, efforts must address educational, social, and economic factors, not just access to clinical services (Ricketts, 1999).
The techniques used to market this new and unique service will vary according to the target audience. General marketing items to promote Family Links include brochures, newsletters, a website, promotional items, and word of mouth.
The key marketing segment is health care providers. Dr. Robert Goldenberg, a premier researcher in preterm delivery, will introduce current research in a local lecture series. Building on past professional relationships, the program coordinator will provide frequent updates on the project status and clinical research. Dr. Ted Holloway, recognized as a preventive health expert, will emphasize and reinforce the need for this project through informal encounters with medical providers. Satilla Regional Medical Center, an active marketing partner, will advocate for this program that prevents preterm deliveries resulting in transfers to other tertiary centers. Dr. Harold A. Bivins, Jr. M.D. of MHUMC has agreed to partner with Family Links to provide referrals and program guidance.
Family Links will be introduced to potential program participants through the health departments and other health care providers. Written material and informational videos will be developed promoting the advantages and benefits of enrolling in the program.
Utilizing formal presentations, informational literature, and periodic site visits, the program coordinator will market Family Links to local and collaborating agencies such as Department of Family and Children Services, hospitals, physicians, and faith/charitable organizations. The coordinator will be active in community interagency groups to emphasize commitment to the community and its families and serve as an information resource.
Potential funding sources will gain insight into the importance of funding for project continuation and expansion based on pilot project outcome data. A newsletter and website will be developed to convey program advances, program data and supporting research. The newsletter will be mailed to potential funding sources. Initial communication will be established through the submission of the project business plan in an effort to secure Department of Medical Assistance (DMA) waiver funding. This marketing strategy will also be used to target foundations and corporations.
All solicitations for abstracts coming to the SEHU will be considered as marketing opportunities. The program coordinator and UNC-MAPH team will be available for presentations. Organizations frequently requesting abstracts include Georgia Rural Health Association, Georgia Public Health Association, Georgia Perinatal Association, Georgia Caseworkers Association, and Family Connection.
The feasibility of the coordinated, intensive home visitation concept will be demonstrated. These efforts will capture the attention of potential funding sources and enable Family Links to secure funds to allow full implementation.
Family Links will establish an advisory board to provide guidance on implementation of this project in the community. The board will ensure community involvement and advocate for system changes and funding sources to support the program. The board will include community leaders, professionals, and client representatives who will meet regularly to lend expertise to further the goals and objectives of the program. Careful consideration to the size and composition of the board will be given to assure balanced representation. Representation will be solicited from early childhood programs, boards of education, public health, cooperative extension service, hospitals, local/state elected officials, health care providers, social service agencies, churches, civic groups, local child and family advocacy community groups, and consumers.
The Family Links staff will consist of a project director, one family assessment worker, two RN family home visitors, and administrative support staff (Appendix C). It is critical to the success of the program that there be an organizational fit between staff selection and program quality. To ensure organizational fit, staff will be recruited who demonstrate the following criteria:
The project director's primary role is to provide on-going, intensive professional supervision to the direct service staff. This person will be responsible for the day-to-day management of the program and will maintain contact with health care providers from whom referrals will come. The director will be involved in program planning, budgeting, staffing, training, program evaluation, and office management.
The family assessment worker will be a social services provider. This person will be responsible for identification and assessment of potential participants in the Family Links program.
The family home visitors will be registered nurses. These nurses will be responsible for initiating and maintaining regular, intensive, long-term contact/support with families. This activity will occur in the families' home. The nurses will be responsible for helping the family establish goals and a plan to accomplish these goals, as well as the assessment of the health and development of each family member.
In order to provide comprehensive family health services, project staff will be trained in the following areas:
Initially, the family home visitor will be responsible for assessments of potential participants for the four county project area. The family support nurses will provide services to families within territorial boundaries. Project participation is voluntary, so intensive outreach will be provided to families to encourage participation. Caseloads will be limited to 20-25 families per worker. Procedures based on family need will be used to determine the intensity and frequency of home visits. Preferably, services will commence immediately after birth and will continue through the child's fourth birthday.
Family Links will operate under the Quality Assurance Plan for the SEHU. This plan is comprehensive and consists of the following elements:
The purpose of the SEHU quality assurance model is to provide a framework for overall quality assurance activities. The process is cyclical and continuous; promoting efficient, effective services based on the results of evaluation, intervention and re-evaluation of processes. A copy of the plan is attached as Appendix D.
The intense planning phase of the project began February 2000. Marketing efforts began in March 2000. The project director and home visiting RN were hired in May. Orientation and training will continue throughout the summer of 2000. The target date for the first home visit to be made is August 2000. See Appendix E for timeline and detailed implementation plan.
Building on the Medicaid reimbursable PCM program format, compliance with State and Federal regulations will be ensured by adherence to established service provision, documentation, and billing guidelines. The quality improvement process will not only address client satisfaction but safety and compliance issues as well. The provisions of the Georgia Board of Registered Professional Nurses Rules allow public health nurses practicing in expanded roles to utilize medical protocols in service delivery. This rule will allow these nurses to provide the screening procedures necessary for the program. The mandated annual protocol review and training will be followed. By virtue of being State of Georgia Merit System employees, public health nurses are covered by blanket malpractice insurance.
Supervisory sessions will be held to reduce the risk of staff burnout and turnover due to the intense stress related to serving overburdened families. All staff will be trained on identification of safety issues associated with home visitation. Each staff involved in home visitation will be furnished a cellular telephone. All staff will be required to wear the agency approved uniform and picture identification. A staff tracking plan will be followed.
If current funding sources decline, the caseload will be referred to the most appropriate categorical program. In this event, Family Links will integrate program knowledge and expertise into existing public health programs.
The program will be self-supporting. With the development of additional funding sources, district wide expansion is planned.
Family Links will save money for families and the health care delivery system. Infant admission criterion to the regional tertiary hospital includes babies weighing less than 1500 grams. The average length of stay at this facility is 52 days at a cost of $3,000 per day. Thus, the cost for each infant is $156,000. Once stable, tertiary care centers back transport these infants to local hospitals as soon as possible for further growth. The local hospital loses the income of delivering the healthy baby when a high risk or complicated delivery is transferred elsewhere.
When babies are born larger and healthier, the cost of care is retained in the local health care system. Because of cost savings, SRMC is a likely funding partner. Another potential funding source is the Georgia Department of Medical Assistance. DMA has expressed concern that categorical Medicaid reimbursable programs for women and babies are not yielding cost effective outcomes. Also, there are a number of federal programs, which might generate resources for Family Links. These options will be explored as funding sources.
Because more private corporations and foundations are seeking opportunities for investing in quality of life enhancements, these entities are likely to have interest in the project. Family Links will seek to secure financial support through social marketing efforts. Contacts have been made with Cooper Abbott Laboratories and Cooper Surgical to partner in providing home screening resources.
It is critical to focus on the need for multiple and diverse future funding sources in order to reduce the impact of reductions or eliminations in current funding. The optimal situation is to have a blend of both public and private funding streams to increase the financial stability of Family Links. (Please refer to financial statements for more details.)
Operations budget | Annual Cash Flow | Annual Balance Sheet