Mothers' helpers: Providers, insurers use home visits to reduce infant mortality

In 2007, Henry Ford Health System in Detroit began to look into ways to address the rate of infant deaths throughout the area, which for years has been one of the highest in the country.

Michigan's infant mortality rate has remained above the national average since at least the 1980s. A major driver is the disproportionately high number of deaths among black infants, who died at a rate that was nearly double the overall rate for the state, at 13.1 for every 1,000 live births in 2013, according to the Michigan Department of Community Health. Detroit accounts for a significant portion of that high rate.

“The infant mortality rate is largely a black infant death problem,” said Dr. Kimberlydawn Wisdom, chief wellness officer at Henry Ford Health.

So in 2008, Henry Ford began collaborating with three competing regional healthcare providers—Detroit Medical Center, St. John Providence Health and Oakwood Healthcare systems—to form the Detroit Regional Infant Mortality Reduction Task Force. The effort, now known as the Women-Inspired Neighborhood (WIN) Network, partners systems with community organizations and local health departments to offer a comprehensive approach—addressing clinical and social factors associated with infant mortality.

“We are taking what we call a 'social determinants of health' approach,” Wisdom said. “We look not only at the clinical (factors) for why these babies die, such as prematurity, but we look at other factors in the home and social factors during pregnancy.”

The program trains community “navigators” who connect women with services that address factors that put them at risk for infant mortality. These include low birth weight, malnutrition during pregnancy, smoking and drinking alcohol. Navigators also help with transportation to doctor visits during pregnancy and nonmedical assistance, such as finding resources for education, employment, stable housing and food.

The WIN Network is one of many approaches around the country developed by healthcare providers and others in recent years to identify and solve the root causes behind a national infant mortality rate that's one of the highest among advanced industrialized countries. Infant death rates vary greatly among the states, with New Hampshire reporting the lowest at 4.2 for every 1,000 live births in 2010, while Mississippi had the highest, with a rate of 9.9 deaths.

A big part of the effort addresses preterm births, a major contributor to infant mortality. Many programs are funded under the five-year, $1.5 billion federal Maternal, Infant, and Early Childhood Home Visiting program, which is part of the Affordable Care Act. State Home Visiting Programs have provided more than 1.4 million home visits since 2012, and in fiscal 2014, they served about 115,500 parents and children through hundreds of programs around the country, according to the U.S. Health Resources and Services Administration.

Among the services the program provides are weekly home visits by a nurse to low-income, first-time mothers under the Nurse-Family Partnership program, first established in the 1970s by Dr. David Olds, a professor of pediatrics, psychiatry and preventive medicine at the University of Colorado Denver.

But the federal home visiting program expires at the end of this month and it's far from certain whether Congress will reauthorize it. President Barack Obama has requested $500 million for fiscal 2016, as well as an additional $15 billion over the next 10 years for the program's continuation.

Preterm birth is defined as a birth that occurs before 37 weeks of pregnancy. The infant mortality rate per 1,000 live births among children born after less than 32 weeks of pregnancy was 70 times greater than for those born between 37 and 41 weeks, according to a January 2013 report from the HHS Secretary's Advisory Committee on Infant Mortality. The Centers for Disease Control and Prevention estimated that the number of premature births in the U.S. totaled more than 450,000 in 2012, which accounts for about two-thirds of all infant deaths up to 1 year of age.

“The premature birth rate is a very high driver for infant mortality in the U.S.,” said Dr. Henry Chong Lee, assistant professor of pediatrics at the Stanford University School of Medicine. “The U.S. does have a significantly higher rate of premature births compared to other countries that are similar to us.”

Preterm birth was estimated to cost employers more than $12 billion a year in excess healthcare expenses, according to a 2014 report from the March of Dimes. The average medical cost for a baby born at full term through its first year was $5,085, of which $4,389 was paid by employer health plans, according to the report. For babies born after less than 37 weeks of pregnancy, the average cost rose to $55,393, of which $54,149 was paid by employer health plans.

Mothers' socioeconomic status has been a key indicator for premature birth, where a correlation has been found between poverty and higher risk for infant mortality. A woman's marital status, her level of education and her age are believed to play a role in determining how much of a risk she faces for infant mortality, according to a study published last September by the University of Wisconsin-Madison's Institute for Research on Poverty.

UHC began its care-management program about five years ago, seeking to identify at-risk mothers and provide them with medical and social resources, said Tracy Davidson, CEO of the plan, which serves about 275,000 Medicaid beneficiaries. Like the WIN Network, coordinators provide transportation for doctor visits, educate mothers on proper neonatal care, conduct home visits and connect patients with assistance programs for food, housing or employment.

“It really became very important for us to be on the ground,” Davidson said. “Telephonic care management certainly has its place, but actually engaging with the community, doing home visits and beginning to have a real relationship with consumers changes the dynamic of how we're able to transform healthcare.”

UHC's program was recognized last year by Ohio Gov. John Kasich for inclusion in a statewide strategy to reduce infant mortality among the Medicaid population in areas identified as having the highest rates.

“Healthier babies being delivered means you have fewer babies in the (neonatal intensive-care unit),” Davidson said. “Providing prenatal care and postpartum care as well as then providing social supports and giving individuals additional resources bends the cost curve from a medical-clinical perspective as well as from a socioeconomic perspective.”

Davidson said her plan's transient membership has made it difficult to obtain definitive data on the care-management program's impact in reducing the infant mortality rate. Another issue is that Ohio's Medicaid managed-care program only started serving beneficiaries on a statewide basis in July 2013. Davidson said she expected to have better outcomes data in the future.

Still, she said the program has seen a reduction in the number of newborn babies with birth weights less than 1,500 grams, which are associated with a higher risk of infant mortality. Also, the infant mortality rate among her plan members is 1% lower than the overall rate for the state.

Follow Steven Ross Johnson on Twitter: @MHsjohnson