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Service Delivery Innovation Profile

School-Based Prenatal Care Coordination Program Enhances Access to Culturally Sensitive Care, Improves Birth Outcomes for Immigrant and Minority Teens


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Snapshot

Summary

The North High School–based onsite medical clinic added an obstetrics care coordination program that provides comprehensive and culturally sensitive prenatal care, education, support, and community resource referrals to pregnant students. Most participants are Hmong or African American and live in low-income households, and many are newly arrived immigrants who have little experience with medical care. In partnership with the school’s Teen Parent Program, the program also provides postpartum and parenting support, including classroom-based education on parenting skills, regular developmental screening for infants, and ongoing medical care for students and their children. The program enhanced access to culturally sensitive prenatal care and increased knowledge and confidence among teens. Additionally, during the 2006–2007 school year, none of the program's participants gave birth to a low birthweight baby or delivered prematurely.

Evidence Rating (What is this?)

Suggestive: The evidence consists of data on program utilization, birth weights and weeks of gestation for babies born to student participants during the 2006–2007 school year, and anecdotal feedback from students participating in the program.
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Developing Organizations

NorthPoint Health and Wellness Center
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Date First Implemented

2002
The North High School–based clinic has been in existence for 30 years. The clinic opened its obstetrics care coordination program in 2002 to include students at North High.begin pp

Patient Population

Age > Adolescent (13-18 years); Race and Ethnicity > Asian; Black or african american; Vulnerable Populations > Impoverished; Racial minoritiesend pp

Problem Addressed

Pregnant minorities and teenagers, particularly those from low-income households, are less likely to access regular prenatal and postpartum care, leading to poor health outcomes for themselves and their babies. Immigrant and refugee populations face additional barriers to accessing these services.
  • Many high-risk teen pregnancies: Teenage pregnancy is on the rise in the U.S., with the teen birth rate reaching 42.5 births per 1,000 teenagers (aged 15 to 19 years old) in 2007.1 Babies born to teenage mothers face an increased risk of poor birth outcomes, including preterm birth, low birth weight, and infant death.1-3
  • Less likely to seek care: Low-income women and girls, particularly young, first-time mothers, are far less likely to access prenatal and postpartum care for themselves and their babies, thus further increasing their risk.1,4,5 Minorities face similar risks; African-American and Hispanic pregnant women in particular are more than twice as likely as non-Hispanic white women to seek prenatal care late or not at all.1
  • Especially among immigrants: More than 50 percent of the students served by the North High School clinic’s obstetrics case management services are Hmong or newly arrived Hmong refugees, a population that experiences significant barriers to accessing health care. Many newly arriving refugees find themselves excluded from existing health systems due to poverty and language barriers. Often, they had limited access to medical care in their country of origin and, as a result, find the U.S. health system unfamiliar and difficult to navigate. Having had little previous experience with medical prevention and treatment, refugees are far less likely than native citizens to access a usual source of care, including prenatal care.6

What They Did

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Description of the Innovative Activity

The North High School–based medical clinic obstetrics care coordination program provides comprehensive and culturally sensitive prenatal care, education, support, and community resource referrals to pregnant students. Most participants are Hmong or African American and live in low-income households, and many are newly arrived Hmong immigrants who have little experience with medical care. In partnership with the school’s Teen Parent Program, the program also provides postpartum and parenting support, including classroom-based education on parenting skills, regular developmental screening for infants, and ongoing medical care for students and their children. Key program elements are described below:
  • Full service, school-based medical clinic: Located at North High School, the clinic operates Monday through Friday from 8:30 to 11:30 a.m., providing a full range of services to high school students and their children. Services include general physical examinations, immunizations, athletic examinations, treatment for minor illnesses, pregnancy testing, prenatal and pediatric care, sexually transmitted infection testing and treatment, dental screenings, mental health counseling, nutrition services, and health education services. Students can receive confidential services, including pregnancy testing, contraception exams and prescriptions, and sexually transmitted infection testing and treatment without parental consent. Consent is required for all other services. Although the clinic accepts reimbursement from private and public insurance, students and their families pay nothing for clinic services.
  • Care coordination for pregnant students: A team of providers and staff, led by a full-time obstetrics case manager, provides coordinated care and support to pregnant teenagers, including:
    • Onsite prenatal care: Students can receive all routine prenatal care at the clinic. Students who need additional obstetrics testing can receive assistance in coordinating and scheduling transportation to NorthPoint Health & Wellness Center, the organization that operates the high school–based clinic, from family members, medical insurance providers or community resource agencies. Because medical appointments can be intimidating to some students, particularly those who have had little previous experience accessing medical care, the obstetrics case manager accompanies students to their prenatal appointments upon request. The case manager helps to ensure that students’ questions are asked, answered, and understood, and encourages students to disclose important health information (such as recent illnesses or medications) to their prenatal providers.
    • One-on-one education and support: The case manager meets with each pregnant student individually once or twice a month throughout the pregnancy. During these visits, the case manager provides education on a variety of pregnancy-related topics, including self-care, nutrition, emotional stress, and family planning. The case manager also provides support and guidance for those students experiencing difficulty communicating with family members about their pregnancies. The case manager also helps students to set and stay compliant with goals for prenatal health, school success, and home life.
    • Links to community resources: The case manager assesses each student’s needs for external resources (such as assistance with housing, food, or job readiness) and connects the student with the appropriate resources in the community. Some community agencies send representatives directly to the school, so that students do not have to make extra arrangements to attend offsite appointments.
    • Cultural sensitivity: Because more than half the students receiving care through the program are Hmong, the program hired a Hmong medical assistant to help with translation or other communication needs whenever the clinic is open. Having a native Hmong speaker is particularly helpful for newly arrived Hmong refugees, who often need help understanding and navigating the unfamiliar American medical system. In addition, printed prenatal education materials are provided in a variety of languages, and all providers and staff attend yearly cultural competency training sessions offered by both the school and NorthPoint Health & Wellness Center.
  • Postpartum and parenting support: The program partners with the high school’s Teen Parent Program to provide additional support for students once their babies are born, including:
    • Classroom-based education: The Teen Parent Program provides teen mothers with a daily parenting class, offered during the school day in a classroom setting. Once each week, the case manager visits the class to present information on any of a variety of health-related topics. Topics include mom and baby health, self-care, life skills, healthy attachment, breastfeeding, family planning, stress management, and postpartum depression.
    • Infant development screening: Also on a weekly basis, one of the clinic’s nurse practitioners visits the parenting class for “mom and baby group,” a time for students and their children to bond and interact in a group setting. The nurse practitioner uses this time to observe each baby’s developmental progress, to offer moms advice and suggestions for sharing time with their children, and to build relationships with each student. The goal is to make them feel comfortable enough to come to clinic staff with any questions or problems they may have in the future.
  • Ongoing medical care for moms and babies: Students may come to the clinic for ongoing comprehensive medical care for themselves and their babies, including well-child visits, immunizations, and treatment of minor illnesses.

Context of the Innovation

The North High School–based medical clinic is operated by NorthPoint Health & Wellness Center, a multispecialty medical, dental, and mental health center and human service agency located in North Minneapolis, MN. North High School is a public, 4-year high school also located in North Minneapolis. It is one of the most ethnically diverse and financially challenged areas in the state. NorthPoint launched its onsite medical clinic at the high school more than 30 years ago. In 2002, clinic providers noticed that more teenage students were becoming pregnant, yet many of these pregnant teens (particularly newly arrived refugees) did not consistently attend their prenatal care appointments. To address this problem, clinic leaders decided to design a care coordination program to support them.

Did It Work?

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Results

The program enhanced access to culturally sensitive prenatal care and increased knowledge and confidence among teens. Additionally, during the 2006–2007 school year, none of the program's participants gave birth to a low birthweight baby or delivered prematurely.
  • Enhanced access to care: During the 2006–2007 school year, the program provided culturally sensitive prenatal care, support, and resources to 27 students. In the absence of the program, these students would unlikely have had access to such services.
  • Increased knowledge and confidence: Students report that the program has increased their knowledge of how to access medical care and resources for themselves and their babies, as well as their confidence in advocating for themselves within the health care system.
  • No low birthweight babies: Birth weights of infants born to program participants during the 2006–2007 school year ranged from 6 pounds, 4 ounces to 8 pounds, 1 ounce, all above the threshold for low birthweight babies (5 pounds, 8 ounces). By comparison, 7.6 percent of all Minnesota teen mothers between the ages of 15 and 19 years old delivered low birthweight babies in 2007.7
  • No preterm births: Weeks of gestation for program participants during 2006 to 2007 ranged from 38 weeks to 40 weeks and 6 days, with an average of more than 39 weeks. Nationally, 14.7 percent of all teen mothers aged 15 to 19 years old give birth before 37 weeks gestation (the cutoff for what is considered a preterm birth).3

Evidence Rating (What is this?)

Suggestive: The evidence consists of data on program utilization, birth weights and weeks of gestation for babies born to student participants during the 2006–2007 school year, and anecdotal feedback from students participating in the program.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Initiating obstetrics care coordination collaboration: NorthPoint Health & Wellness Center had instituted a prenatal care coordination program, “Healthy Start,” to work with high-risk prenatal patients. In 2002, the North High School–based clinic manager requested that the program be expanded to include the school-based clinic prenatal patients. As mentioned above, the clinic was seeing an increasing number of pregnant adolescents for prenatal care, including an influx of newly immigrated Hmong refugee pregnant and parenting adolescents who were having difficulty navigating the health care system. NorthPoint Health & Wellness Center agreed to expand the “Healthy Start” program to the school-based clinic.
  • Building network of community resources: The program collaborated with school and community organizations that could provide important resources to North High School’s pregnant and parenting teens. Clinic providers attended provider and obstetrics case management meetings and trainings to identify outside resources for students.
  • Utilizing community advisory board: NorthPoint Health & Wellness Center's community board provided initial approval for participation in the "Healthy Start" program, sets priorities for programs and services provided by NorthPoint clinics, and provides ongoing guidance in decisions regarding the school-based clinic's obstetrics care coordination program.
  • Continual championing of program: Grant funding to the school-based clinic was recently cut. Program staff continue to communicate with clinic administrators and stakeholders about the importance of offering obstetrics care coordination services to the students at North High School. To help maintain administrative support, key North High School personnel (including teachers, coaches, and administrators), patients, and parents have mobilized to share personal stories of how the program has positively affected the lives of students.

Resources Used and Skills Needed

  • Staffing: Obstetrics care coordination is provided by a full-time employee who spends 20 percent of her time on case management and the other 80 percent on health education. Additionally, a family physician, a family nurse practitioner, a medical assistant (who is also a Hmong interpreter), and a health receptionist participate in providing prenatal care for students. NorthPoint Health & Wellness Center employs all clinic staff.
  • Costs: The annual budget for the clinic runs approximately $113,000, with the obstetrics care coordination program representing a relatively small portion of these expenditures. Approximately 20 percent of the salary and time of the obstetrics case manager and the medical assistant support the obstetrics care coordination program based at North High School.
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Funding Sources

United Way; NorthPoint Health and Wellness Center; Hennepin County (Minnesota)
NorthPoint Health & Wellness Center provides staff hours to the clinic as an in-kind donation.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Assemble dedicated team: Ensure that all providers and staff have knowledge of and a vested interest in providing health care to an underserved student population. To successfully reach its target audience, the program must make students feel welcomed and respected by a team of caregivers truly interested in helping them set and achieve health-related goals.
  • Understand the community: All program staff should be aware of student demographics and strive toward cultural competency in their interactions with patients and their families. To that end, offer training and inservice sessions on cultural sensitivity and on strategies for overcoming barriers to care.
  • Set goals early: Take time early in the planning process to establish core programming and outcomes-related goals. Ensure that all staff, particularly frontline providers, are aware of these goals and committed to achieving them.

Sustaining This Innovation

  • Search broadly for funding and other support: Continually seek innovative ways to secure and maintain support for the program, including not only money, but also in-kind donations of space, staff, and resources.
  • Consider expanding hours: Make sure that the program’s hours of operation coincide with student needs. If funding allows, consider offering clinic hours before or after school, so that students do not have to miss classes to receive program services.
  • Gather anecdotal reports: Student stories can go a long way in garnering community and administrative support for the program. To that end, record and share the personal accounts of students whose lives have benefited from program services.
  • Initiate, and learn from, evaluation: Gather feedback from students and teachers about their perceived areas of need and the program’s strengths and weaknesses in meeting these needs. Incorporate their feedback and suggestions into ongoing evaluation and refinement of the program.

More Information

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Contact the Innovator

Ann Sweeney, RN, MS, CNP
Pediatrics Department
NorthPoint Health & Wellness Center
1313 Penn Ave. N.
Minneapolis, MN 55411
Phone: (612) 543-2657
E-mail: Ann.Sweeney@co.hennepin.mn.us

Brenda Lynn
Community Health Specialist
NorthPoint Health & Wellness Center
1313 Penn Ave. N.
Minneapolis, MN 55411
Phone: (612) 668-1740
E-mail: Brenda.Lynn@co.hennepin.mn.us

Innovator Disclosures

Ms. Sweeney and Ms. Lynn have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in the profile.

References/Related Articles

NorthPoint Health & Wellness Center’s informational Web page on the medical clinic is available at: http://www.northpointhealth.org/ClinicalServices/MedicalClinic/MedicalClinicAtNorthHighSchool/tabid/108
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Footnotes

1 Heron M, Sutton PD, Xu J, et al. Annual summary of vital statistics: 2007. Pediatrics. 2010:125(1):4-15. [PubMed]
2 Mathews TJ, MacDorman MF. Infant mortality statistics from the 2005 period linked birth/infant death data set. Natl Vital Stat Rep. 2008;57(2):1-32. [PubMed]
3 Gavin L, MacKay AP, Brown K, et al. Sexual and reproductive health of persons aged 10-24 years—United States, 2002–2007. MMWR Surveill Summ. 2009;58(6):1-58. [PubMed]
4 Hoffman SD, Maynard RA, eds. Kids having kids: costs and social consequences of teen pregnancy. Washington, DC: Urban Institute; 2008.
5 Aved BM, Irwin MM, Cummings LS, et al. Barriers to prenatal care for low-income women. West J Med. 1993;158(5):493-8. [PubMed]
6 Kaiser Commission on Medicaid and the Uninsured. Immigrants' health care coverage and access [Web site]. August 2003. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/01
/immigrants-health-care-coverage-and-access-pdf.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
7 Minnesota Organization on Adolescent Pregnancy, Prevention, and Parenting. 2009 Minnesota adolescent sexual health report. Available at: http://teenwisemn.org/Documents/2009AdoHealthReport.pdf
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Original publication: July 21, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 29, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
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