1. C-4, In the beginning… How to Implement an Early Start Program Jennifer Krieger Riley, MA MCH Project Director, Harrison County Health Department Hope Crail Billing/Administrative, Harrison County Health Department

2. Objectives Give an overview of the Title V Program Discuss the MCH programs currently taking place in Indiana Describe the components of the Early Start Program Specifically discuss the implementation of the Early Start Program in Harrison County Discuss Medicaid Billing

3. What is the Title V Block Grant? Enacted in 1935 as a part of the Social Security Act, the Title V Maternal and Child Health Program is the Nation’s oldest Federal-State partnership.

5. TITLE V PROGRAMS INDIANA Currently fund 46 grantees throughout Indiana Focus on issues related to: Infant mortality Pregnant mothers Family planning Children’s health Adolescent health Oral health CYSHCN Indiana Family Help Line

6. Infant Mortality- Indiana Infant Mortality is Indiana’s #1 Health Priority In 2011 Indiana had 7.7 deaths/1000 – Indiana is 45th worst out of 51 states (includes DC) in 2011 – IN consistently one of the worst in USA – Indiana only <7.0 once in 113 yrs!! 6.945 in 2008

7. What causes infant mortality?

8. Top 5 Causes of Infant Mortality 1.Born with a serious birth defect 2.Born too small or too early Preterm <39 weeks Low Birth Weight (LBW) Weight less than 5lbs 8 oz (2500 grams) at birth Very Low Birth Weight (VLBW) Less than 3lbs 5 oz (1500 grams) at birth 3.Sudden Infant Death Syndrome (SIDS) 4.Affected by maternal complications of pregnancy Diabetes, hypertension, obesity, etc. 5.Victims of injuries Suffocation deaths

9. Risk Factors for Infant Mortality Smoking during pregnancy Drug use during pregnancy Drinking alcohol during pregnancy Late prenatal care

10. Prenatal Care Coordination The primary goal of Prenatal Care Coordination is early entrance and continued participation in prenatal and postpartum care to reduce low birth weight, preterm labor, and infant mortality.

11. Barriers to Early Prenatal Care  One of the main barriers to receiving 1 st trimester prenatal care is the increasing number of unplanned pregnancies.  Transportation to prenatal care visits is a problem for many low-income pregnant women, especially those in rural areas.  Many low-income pregnant women do not receive early prenatal care because they are not aware of available resources. This is common for women who are not already enrolled on Medicaid.

12. Early Start Program- History  In the late 1990s the Indiana State Department of Health investigated the infant mortality rate in Indiana and found that 80% of mothers whose child did not reach his or her first birthday had not received 1 st trimester prenatal care.  After investigating these findings, the Early Start Program was developed.  This program aimed to help low-income women receive 1 st trimester prenatal care.  This program has been active in Harrison County and Kosciusko County for over a decade.

13. Goals of the Early Start Program  Increase the percent of pregnant women receiving prenatal care in the first trimester  BMI assessment and education on appropriate weight gain and nutrition  Prenatal education regarding smoking, alcohol, and drug use  Prenatal education regarding folic acid  90% of all pregnant women found to be at high-risk at the time of the Early Start assessment will be seen by a physician within two weeks of referral

14. Early Start- Program Policies  Early Start Programs shall be affiliated with a free pregnancy testing program that provides outreach activities to find high-risk pregnant women  The Early Start Program may be coordinated by a Registered Nurse, Nurse Midwife, OB  The project must have access to a physician or certified nurse midwife providing prenatal care to the identified population  Memorandums of Understanding with WIC office and county Medicaid office

15. Early Start- First Encounter  Health and Pregnancy History  Prenatal Risk Assessment  Nutrition Assessment  Height/Weight/ BMI  Prenatal Labs  Dispense Prenatal Vitamins  First Trimester Education  Medicaid Enrollment if Eligible  WIC Referral  Social Services Referrals  Prenatal Care Coordination Referral

16. Early Start: Follow-up  Women identified as high risk medically are referred to sponsoring physician within 1-2 weeks  Women not at high risk are seen in the clinic until they get Medicaid or choose to leave to be seen by a prenatal care physician

17. A Little About Us…… Harrison County MCH was opened in 1970 in a small apartment building in Corydon, IN as a division of the Harrison County Health Department We moved to our newly renovated facility in January 2011 100% of grant funding goes to patient care

18. Funding Harrison County MCH works off of two Title V Program Grants from the State of Indiana – MCH Title V Grant – Title V – Infant Mortality Grant – new this year Utilize sliding scale based on income

19. Just the Facts Average 130 prenatal patients per year ranging in ages from 14- 40 Harrison County MCH serves Crawford, Floyd, Harrison, Orange and Washington counties for prenatal healthcare Local OB/GYN donates his time one day a week to come to clinic to see MCH patients

20. Who Qualifies? Patients who will receive Medicaid Benefits Patients who will receive Package E – Medicaid Benefits Uninsured/Under Insured Patients *** Once Medicaid benefits have been received, patient is discharged to Physician of their choice.

21. How it Works??? Our goal is to enroll patients before 12 weeks gestation (1st Trimester) Utilize the concept of Life Course Perspective Help new mother to take care of herself so she can take care of baby once he/she arrives

22. Enrollment Visit  Assess height, weight and determine BMI  Educate on proper nutrition  Evaluate for Sexually transmitted infections  Stress importance of not smoking  Evaluate patient for drug/alcohol use  Family history/health issues  Assess for housing/transportation needs  Assist with Medicaid application/Claim Aid  Educate on Prenatal Vitamins/Patient given a bottle of vitamins and prenatal workbook during visit

23. Educate, educate, educate!!!! Patients are educated on a variety of topics during enrollment and this information is reinforced during each patient visit. – A few of these include: Smoking, drugs, alcohol, caffeine (ASK Form) Warning Signs Breastfeeding Safe Sleep Practices SIDS/SUIDS Car Seat Safety

24. Did I say educate? We educate and assess on smoking status at each visit STI’s Reinforce signs of miscarriage/preterm labor Prenatal Vitamins/Folic Acid Nausea Assess for areas of high risk

25. Needs Assessment Transportation Food, Clothing, Shelter Family/Friend Support Emotional Well-Being Health History/Conditions History of Abuse Stressors

26. Barriers to Early Intervention Denial – Patients feel that if they ignore the issue, it will go away Lack of knowledge of available resources Family doesn’t want patient to come to clinic Afraid to come due to alcohol/drugs No reliable transportation/no gas money School/work schedules Court Cases/Custody Issues

27. Everything you need to know about Medicaid and Billing Medicaid Claim-Aid Copays Coding Helpful Hints

28. It takes a village…….. Partnerships Harrison, Crawford, Washington and Orange WIC Offices Indiana State Department of Health Harrison County Hospital/HCH Dietician Free Pregnancy Testing Program Claim Aid – A service provided by Harrison County Hospital Local Medicaid Office Harrison County Hospital Harrison County Healthy Families Early Head Start Harrison County EMS – Car Seat Program Harrison County Community Services Local Churches/Food Pantries/Pack-n-Play Donations State STD Program – Free Condoms Ramsey Popcorn Indiana State Tobacco Quitline

29. Important things to remember……. Be patient, but consistent Patients will LIE In some cases MCH Staff is the only support patient will have Patient will not always know health history or Social Security # Applying for Medicaid is not always a priority to patients You want them to come to an appointment at 8:00 a.m. What?

30. Successes Babies have a much better chance when prenatal care begins early Smoking Cessation Encourage patients to continue care after baby arrives Birth control, annual pap smears, prevention, STI screenings Birth Spacing Consistant support system for patients

31. Challenges Patient Compliance Transportation Medicaid Compliance Patient is only concerned with ultrasound Drug Use/Smoking No Patient Support

32. Thank you for your time. A very special thank you goes to Theresa Hunter from ISDH for allowing us to use the content of her slides from our presentation at the Indiana Rural Health Conference. Contact Information: Jennifer Krieger Riley, MA MCH Director Harrison County Health Department Harrison County Health & Education Building 241 Atwood Street, Suite 100 Corydon, IN 47112 (812) 738-3237, Option 2 JenniferR@harrisoncounty.in.gov