1. Creating a Medical Maternity Home With Four Different Addresses Jennifer Frank, MD, FAAFP University of Wisconsin School of Medicine and Public Health

2. Learning Objectives Identify barriers to vulnerable patients’ ability to find and identify a medical home Identify technology-based and innovative strategies to develop a medical home concept for at-risk patients Visualize a medical home concept for all of their patients

3. The Challenge Develop a prenatal and postnatal medical home for the “medical homeless”.

4. The patient population Poor women, many non-English speakers who received care at a local Federally Qualified Community Health Center.

5. Four Sites of Care Appleton Medical Center St. Elizabeth Hospital Fox Cities Community Health Center UW Health Fox Valley Family Medicine Residency Clinic

6. The Way Things Worked Prenatally Pregnant patient enrolls at Fox Cities Community Health Clinic Receives Care Until 28 Wks GA Lost to F/U 1. Referred to UW Health Clinic 2. Referred to another FM Clinic 3. Referred to local OB 4. Lost to Follow Up

7. What happened at time of delivery Patient in Labor Patient delivered by her “primary” physician at designated hospital Patient delivered by another physician at designated or other hospital Health Center Informed Health Center Not Informed

8. What happened with postnatal care Patient discharged from hospital with follow-up instructions PP Visit at Comm Health Center PP Visit with delivering FP Postpartum visit with delivering OB Lost to follow up

9. Practical Problems Prenatally Poor or no continuity Records lost/incomplete/unavailable Things “lost in transition” Postpartum Uncertain postpartum destination No after-hours person to call at the Community Health Center No confirmation that PP care was received

10. Keys to the Solution Communication Financial Keeping patients in their medical home

11. Communication at points of transition Initial entry to care 24-28 weeks gestation Immediate postpartum 6-8 weeks postpartum

12. Communication between caregivers Fox Cities Community Health Clinic Fox Valley Family Medicine Clinic St. Elizabeth Hospital Appleton Medical Center

13. Communication with patients Identifying a primary physician Site of care Division of responsibility Identifying patient desires/goals

14. Financial Fox Cities Community Health Clinic Expending resources for Medicaid enrollment Attempting to keep revenue at the clinic Different billing fees depending on number of prenatal visits/site of postpartum care Keeping insured patients at “home”

15. Financial continued Fox Valley Family Medicine Residency Clinic History of providing “free care” Appropriate payment for delivering physician Maximizing continuity for residents vs. financial considerations of the community health clinic

16. The Patients’ Medical Home Fox Cities Community Health Clinic Not esteemed as highly as other traditional clinics Freedom with Medicaid enrollment Language barriers Relationship built with delivering physician or established pediatrician Lack of continuous regular clinicians at the community health clinic

17. In the midst of a mess… What were our goals? Provide top-notch care to a vulnerable patient population Maximize communication between 4 points of care, particularly regarding medical record transition Keep community health clinic patients at “home” Nurture a professional relationship between the residency clinic and community health clinic Minimize “lost to follow up”

18. Use of Innovative Strategies CenteringPregnancy Midwife developed 10 sessions of group prenatal care 8-10 women Stable facilitators All care provided within group space Patients take part in own care Education and support focus

19. Achieving the Goal CenteringPregnancy Proven outcomes Proven with at-risk populations Could be conducted in English or Spanish Allowed advance planning Mobile

20. After CenteringPregnancy… Modified use of CenteringParenting 12 months of well child visits in group setting Located at patient’s medical home Transition point back to medical home

21. Use of Technology At baseline, only Appleton Medical Center and the community health clinic shared a record eNatal – internet based electronic prenatal health record Available at all 4 care sites…and beyond Available to patient Data entered by nurse with patient at CP visit

22. Achieving the goal - Financial Still in progress Treat group visits like individual prenatal visits Grant funding eNatal purchase CenteringPregnancy Training Supplies

23. Resident Role Four residents received CP training 2 residents are assigned to each CP group Group led by faculty physician All group patients assigned to one of residents for continuity delivery Will assume well-child group visit leadership

24. Challenges we faced Original core team largely changed Selling to the “board” Hospital involvement (or lack thereof) Slower than anticipated eNatal Dynamic system Enrollment

25. What went well Our clinic’s enthusiasm Administrative support CenteringPregnancy Advocate at the Community Health Center Grant funding Health educator

26. Current status Decided to mix groups First group in November Second group in January Plan for 18 month session Fully funded eNatal

27. Outcomes we will study Patients knowledge/satisfaction Prenatal care Anticipatory guidance Breastfeeding intent and success >90% of prenatal visits 100% of immunizations 1 st trimester prenatal visit

28. What was learned There’s a reason the problem existed in the first place Medical home is not a building but a philosophy of care Very little needs to be invented – just modified A primary clinician is key

29. Questions/comments