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II. PROJECT NARRATIVE

A. Project Abstract

There is no greater cost to a community than the life lost of a newborn baby. The

Hollywood Health Loop Clinic (HHLC) in North Memphis knows this all too well. That is why

in March 2006, they began a pilot project to educate the women in their community about the

importance of prenatal care and its link to the prevention of premature babies and infant

mortality. HHLC, part of the Regional Medical Center at Memphis network of community

healthcare centers, plans for the pilot to expand their services to pregnant women through

Prenatal Education Seminars. This initiative will address the on-going issue of pregnant women

not seeking prenatal care or seeking it late in their pregnancy. Memphis has one of the highest

Infant Mortality Rates in the nation. Premature birth is a known contributor to infant mortality.

Prenatal care and education on this issue play key roles in preventing premature births.

The Prenatal Education Seminars will focus on educating women, 97% minority, on the

importance of prenatal care through an Orientation session and additional educational classes in

order to improve the health of mothers and babies in their community. Many of the patients are

classified as high risk because of socio-economic factors or health issues, such as age or race.

The Orientation focuses on building trust with the patient through a team approach, education,

immediate care and access. The pilot program is a great success: 96 pregnant women attended

the Orientation and began seeking service by the clinic, a 43% increase in women served from

2005. The success of the program will continue as the clinic increases the number of women

seeking care and seeking care earlier in pregnancy. Overall success will be established when the

project becomes a Best Practice model for other Health Loop Clinics in the Memphis

community.

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B. Description

Funding Priority

The Hollywood Health Loop Clinic (HHLC), part of the Regional Medical Center at

Memphis (The Med) network of community-based healthcare centers, is expanding current

services to pregnant women in Memphis by educating women about the importance of prenatal

care and aftercare for their child through the Prenatal Education Seminars. The project is focused

on the March of Dimes priority area of Enhancing education and support services for high-risk

pregnant women. Through the Prenatal Education Seminars, HHLC will address the community

need for education for minority pregnant women who do not seek prenatal care or seek it far into

their pregnancy, thus compromising their health and the health of their babies. The program will

lead to an increased knowledge about the importance of prenatal care, an increase of pregnant

women seeking prenatal care, earlier prenatal care, reductions in no show rates, increased

knowledge of pregnancy, birth and newborn care and higher patient satisfaction. Funds will be

used to continue and expand the successful pilot program that began in March 2006. The grant

will purchase educational materials from March of Dimes, office supplies, brochures, mail-out

materials and incentives such as diapers and gift cards.

Community Need

The initiative will address the on-going issue of pregnant women not seeking prenatal

care. Often, these women have a high number of chronic conditions and health issues, yet do not

recognize pregnancy as a condition that justifies doctor visits. Other factors such as lack of

transportation, fear of others knowing of their pregnancy, and inability to pay contribute to

women not showing up for appointments or not making an appointment until the third trimester.

This can lead to a compromised health status of both the mother and the baby, often manifested

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in premature births and visits to the Emergency Room (ER) instead of the OB-GYN clinic. The

Commercial Appeal’s Special Report: Infant Mortality in Memphis (March 5, 2005) reported

Memphis’ Infant Mortality Rate (IMR) was twice that of the national average, with non-white

IMR at 19 deaths of every 1000 babies born. What is even more pressing for the HHLC is that

the area surrounding the clinic, which includes North Memphis' 38108 and the communities of

Douglass and Hollywood, “is deadlier for babies than Vietnam, El Salvador and Iran.” Premature

birth is a known contributor to infant mortality. Prenatal care and education can reduce the risk.

Impact on Community Health

Education on prenatal care and its importance are the key factors in the Hollywood

Health Loop’s project plan. The project will impact the mortality and premature birth rates

facing the clinic’s community. Additionally, the team plans for patients to be better informed

about their options for healthcare and community resources. Premature babies and high-risk

pregnancies put a significant strain on community health resources such as The Med where most

of the women in the program will have their babies. Regular visits to the clinic for prenatal care

will reduce emergency room visits thereby further reducing the strain on the resources of The

Med. Many of these women have little to no health insurance and may be relying on state funded

health programs or be self-pay. Even saving one admission to the Neonatal Intensive Care Unit

(NICU) would significantly reduce the financial burden to the community. In fiscal year 2006,

average length of stay for a baby in NICU was two weeks at a total average cost of $42,993.

Target Population

Almost 100% of the women who will attend these classes are from minority groups: 36%

Hispanic and 57% African-American. Approximately 75% range between 19 and 35 years of

age, but some are as young as 14 and as old as 46. Some have little to no formal education while

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others have high school to college education. Most of the Hispanic patients are from Mexico

where formal schooling for girls is required only up to the sixth grade. Patients come to the clinic

from all over the city, but three-fourths live nearby. They are classified as high risk because of

socio-economic factors, health issues, age, and race. The health issues may include previous

premature births, or chronic disease. Many are classified as low-income and require additional

services from other health agencies to meet the needs of their newborn babies. Over 42% do not

have insurance, while 51% rely on TennCare, the state-funded healthcare program. Many either

do not have a permanent living arrangement or live with many family members in small

apartments/homes.

Organizational Capacity

Dr. Linda Moses and the OB Team designed and implemented the pilot program in

March 2006. The OB Team includes an OB nurse, a medical assistant, an interpreter, a medical

social worker, community advocate, pediatric nurse and Dr. Moses, an OB-GYN physician.

They will provide the primary support for the program’s implementation with the help of Project

Manager and Community Program Coordinator, Patricia Hipps. Combined, they have over 51

years of experience dealing with high-risk pregnancies.

HHLC is a part of the Med’s network of community –based healthcare centers that began

in 1999. The centers provide independent and collaborative healthcare services within the Shelby

County Healthcare Network. The purpose of the clinic is to provide primary care that is

accessible, efficient and high quality to residents of Memphis and Shelby County. They offer a

sliding-scale fee for patients and varying services, including primary and episodic care for adults

and children and specialty services of obstetrics, gynecology and dentistry. Dr. Moses began the

Moses Community Coalition which helps the North Memphis neighborhood where she grew up.

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The coalition is made up of The March of Dimes, First Year Institute, Memphis City Schools,

The Memphis Fetal Alocohol Spectrum Support Network and several other organizations. The

clinic partners with the coalition, the Memphis/Shelby County Health Department, the Med and

other Health Loop clinics to provide better healthcare across all areas to disadvantaged residents

of their community.

Project Publicity and Dissemination

The clinic will develop a program brochure to distribute to patients, place at The

Birthplace, The Med’s birthing center, and share at regular meetings of social workers,

physicians and other organizations. The Med will handle additional publicity for the program

through their newsletter Resource, which is distributed to 2,500 employees. March of Dimes will

be acknowledged in any press release that is written and in the program brochure.

Information about upcoming classes will be presented to patients at Orientation. Mail-

outs will be used to follow-up which has been successful in previous clinic programs. The

patients are asked to give a permanent address where they can be reached for information

regarding their pregnancy. While many patients may be transient, they usually have a permanent

mailing address either through a relative or friend. In the past, if the patients could not be

reached by phone, many showed up for class with letter in hand. Phone calls are used, but are not

as reliable as the permanent address that patients give.

The HHLC expects the project to be a Best Practice model for the two other Health Loop

Clinics that offer OB services in the Memphis community. HHLC plans to communicate their

results through the Health Loop system at monthly manager’s meetings, provider’s meeting and

Health Loop Board meetings, and to similar organizations that serve the same populations.

C. Project Objectives, Activities and Methods

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Project Planning

The Prenatal Education Seminars began in March 2006 as a pilot program for the clinic.

The project is planned around four key components: a team approach, immediate care, education,

and access to care and resources. Services are delivered through weekly Orientation sessions for

up to 12 patients and monthly educational classes for up to 10 patients.

The first step in the process is the three-hour Orientation that is the initial prenatal visit

for each patient. During Orientation, the patients meet the entire OB Team focusing on building

trust with the patient, a central factor in its success. During this time, patients have many

opportunities to ask questions and interact with the team both corporately and individually as

they go through the morning activities. This ensures the women will return to receive additional

prenatal care provided by the OB-GYN physician. An appointment is made for them to be seen

by the OB-GYN physician based on their individual gestational stage of pregnancy.

The second focus is to provide immediate care. Before the Orientation, at least one-fourth

of patients waited until the third trimester to receive care and other clinics had waiting lists of

two to three months for appointments. With regular Orientation classes, the HHLC ensures they

will be able to see any woman who might need prenatal care in a timely fashion. The Orientation

also allows them to get their paperwork and the initial assessments finished, ensuring that the

first visit with the physician will be more effective. This increases the OB-GYN’s ability to see

additional patients. Receiving prenatal care from the clinic means the women have a continuous

connection with the clinic through The Med’s 24-hour call number or access to a member of the

OB Team.

The third component is education. During Orientation, the women are engaged in a

discussion with the OB nurse concerning danger signs of pregnancy, what medicines they can

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safely take, how their bodies change during pregnancy, and how to recognize normal changes, as

opposed to those that could put them at risk, including premature labor. The clinic’s nurses

perform blood work to check for any additional health issues and provide information to the

women. An interpreter is available for Spanish-speaking women. The interpreter is an integral

part of the process, from registering at the front desk to the meeting with the social worker.

During classes and group sessions, the interpreter uses the consecutive mode of interpreting:

what is spoken in English is followed by Spanish in phrases or sentences. Another major focus of

the program will be to provide information about dental care and to provide supplies for proper

dental hygiene such as toothpaste and toothbrushes. The clinic will work to collaborate with the

UT Dental program and other programs to receive the dental hygiene supplies. They also watch

informational videos in both English and Spanish on the importance of getting prenatal care,

folic acid, signs of preterm labor, 1st, 2nd, and 3rd trimesters, labor and delivery, the first three

months of life, safe sleep, breastfeeding and other necessary topics. It is important that both the

videos and the materials give information about all three trimesters so that each patient receives

knowledge about her whole pregnancy. At the end of the Orientation seminar, they will receive a

“Baby Basics” book providing information on their pregnancy. Much of the grant funds will be

used to provide educational materials When appropriate, any handouts and materials are

provided in Spanish.

During the pilot Orientation sessions, the OB Nurse conducted an informal survey to

determine what type of classes most interested the patients. Based on their feedback, the

Aftercare for Moms and Babies and Labor & Delivery Classes were chosen. At the Orientation,

the social worker will explain to each patient about the classes and try to get them to sign-up for

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an upcoming class. After they have signed up for a specific class, then the Monday before the

class, the social worker sends a reminder letter about the upcoming class to the patient.

The classes are voluntary to the patients. Topics covered in Orientation and through the

classes are selected from the Baby Basics Book as deemed appropriate by the OB Nurse and Dr.

Moses from their experience dealing with high-risk pregnant women. The highlights in chapters

covering all three trimesters of pregnancy have been reorganized into a simpler format and are

presented in a way to encourage participation by patients. If an area is of interest to many of the

patients, then the topic is covered more fully by the staff. For topics not covered in depth,

handouts are provided for patients and they are instructed to call the OB staff if they have

questions.

The last focus of the project is access to resources. During the Orientation, the clinic’s

social worker assesses the women on their overall health, psychosocial well-being, financial

position, and health history. Through this process, she is able to make appropriate community

referrals depending on their needs. Some are referred to counseling programs, others referred to a

GED program. Still others are encouraged to enroll for the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC). Almost all of the women have some need that

is able to be addressed through this process. The community referral process is a significant

component as it ensures the longevity of life for the mother and the baby past pregnancy. A

young woman who receives her GED has more options for herself and her baby than before.

Patients also receive information on community resources and coupons from local stores and

restaurants. Incentives are offered including gift cards to Kroger and diapers to help meet some

of the needs of their newborns and to encourage further participation in prenatal visits and

classes by the patient.

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Project Goals & Objectives

The project will educate pregnant women about the issues involved in having a

successful pregnancy, provide earlier prenatal care for mothers and babies and teach the

appropriate use of community health resources.

Objective 1: To educate women about prenatal care

Activity 1: Hold 10 classes each per year in Labor & Delivery and Aftercare for Mother & Baby

Activity 2: Hold 40 Orientation sessions through-out the year for approximately 10 to 12

patients.

Objective 2: To provide improved access to prenatal care

Activity 2: Hold 40 Orientation sessions through-out the year for approximately 10 to 12 patients

Objective 3: To teach the appropriate use of community health resources

Activity 3: Education through the Orientation and classes on the appropriate use of community

resources including the clinic, OB Team, The Med, Emergency Rooms and other resources.

Project Management

The project is managed by Patricia Hipps, Coordinator of the Health Loop Community

Program. She will oversee the project and, with assistance from Dr. Moses, establish

measurement guidelines for when and how to measure the program goals. Data collection will be

done quarterly by the project manager to review progress. The instructor will administer

satisfaction surveys at the end of each Orientation and pre/post surveys during each class. The

results will be compiled quarterly by the project manager.

The Team will work closely together and have regular progress meetings related to the

overall service they provide. At these meetings, the team will adjust the program as needed and

will monitor any progress toward goals and objectives. As a member of the Shelby County

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Health Care Network, the clinic collaborates with other Health Loop clinics and The Med

through their programs.

D. Evaluation Plan

The evaluation plan will analyze and present the results of pre/post surveys as well as

other data to evaluate the success of the program. A pre/post survey administered by instructors

will compare what patients know at beginning of class and at end of class based on topics

covered for all three classes. A satisfaction survey administered by the instructor will gauge

patient’s opinions about each session and will be used to make needed changes to the process.

The project manager has developed the surveys with collaboration from The Health Loop’s

researcher, Dr. Diane Pace as well as clinic staff including Dr. Moses, the OB Nurse, the

pediatric nurse and the pediatrician. Data will be collected by the project manager on number of

pregnant women attending Orientation and classes, the trimester of pregnancy at initial visit, and

number of no-show for appointments. The data and survey results will be compiled by the

project manager and used to analyze the program with assistance from the Health Loop Reports

Analysis Compliance Manager. The project manager will then make recommendations, review

them with program staff and implement selected program improvements or changes.

Measurements

Objective 1: To educate women about prenatal care

Outcome 1.1: Increase knowledge regarding pregnancy, birth, and newborn care with 80 % of

patients scoring 90% or better on post test

Outcome 1.2: Measure patient satisfaction through maintaining an Overall Above Average

score on satisfaction survey (Level 4 out of 5)

Outcome 1.3: Educate 400 pregnant women in Orientation and 100 in classes

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Measurement 1: Pre/Post survey will measure education on pregnancy and prenatal care

and Satisfaction survey will measure patient satisfaction

Measurement 2: Data collection will be gathered on the following: a.) Number of OB

patients at clinic, b.) Number of pregnant women attending Orientation and c.) Number of

pregnant women attending classes

Objective 2: To provide improved access to prenatal care

Outcome 2.1: Increase patients served from 150 to 400 annually

Outcome 2.2: Encourage earlier prenatal care with 70% of patients attending Orientation

during 1st trimester.

Measurement: Data collection will be gathered on the following: a.) Number of OB patients

at clinic and b.) Identification of trimester at initial visit

Objective 3: To teach the appropriate use of community health resources

Outcome 3.1: Reduction in no-show rate 20% (from 50% to 30% ) for prenatal visits

Measurement: Data collection will be gathered on number of no-shows

Successes & Challenges

The pilot program was a great success. During the pilot, 96 pregnant women attended the

Orientation, a 43% increase (from 67 patients to 96 patients) in the number of women seen by

the clinic during the same time in 2005. Additionally, the women seen during the pilot have

come in sooner in the pregnancy for prenatal visits. During 2005, only 45% (30 patients) of

women came during the first trimester. During the pilot period in 2006, 65% (62 patients) of

patients came during the first trimester. Even more significant is that during the pilot program

only 5% (5 patients) of patients were in the third trimester when first seeing the doctor, while in

2005, one-fourth (16 patients) of patients waited until the third trimester to visit the doctor.

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The Hollywood Health Loop Clinic plans for this project to be replicated will be one

measure of success. Success will also be achieved from increased education and higher numbers

of women served by the clinic. Another indicator of success will be healthier babies born to the

women who attend the clinic. One challenge is that women make appointments and then do not

show up. HHLC will educate the women on the importance of receiving adequate care and

maintaining consistency in appointments. Another challenge is that even if women do

everything right, there is still some chance of premature birth. Additionally, the program must

overcome education and economic barriers. Lack of education is one of the key factors which the

clinic plans to overcome by using material that is taught on a 6th grade level as well as providing

hands-on and visual training. Furthermore, reaching women who really need the service is a

challenge the clinic must overcome. HHLC will encourage women to refer friends, family

members and acquaintances and promote the program to the community.

E. Project Impact

Anticipated Impact

The impact of the project will be seen through the increased knowledge of the patients

and earlier incidence of prenatal care. As mothers receive the proper prenatal care, their health

and their babies health will be better. The quality of life for their baby will be enhanced as they

learn to better take care of themselves and their baby through the classes. Often there is the fear

of the unknown especially for first-time mothers. Receiving support through prenatal care and

the classes will help them to be better prepared for changes that are occurring in their lives.

Sustainability

Hollywood Health Loop Clinic will establish the seminar as a best practice model.

Establishing the program model and building the prenatal program will help the Health Loop

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system to become Federally Qualified Health Center (FQHC) certified. Becoming FQHC

certified means more federal dollars for the center, allowing it to expand services to the

underserved in the urban community. If their success is proven, HHLC will seek to become a

preferred incentive provider for TLC for which 15-20% of current patients qualify. TLC is the

Family Care Health Care plan of the Memphis Managed Care Corporation that is sponsored by

the Med and UT Medical Group. Through TLC, HHLC will seek additional funding to continue

and expand the program.

Prenatal Education Seminars Hollywood Health Loop Clinic July 20, 2006

OBJECTIVE # 1 To educate women about prenatal care

OBJECTIVE # 2 To provide improved access to prenatal care

OBJECTIVE # 3 To teach the appropriate use of community health resources

1. Hold 10 classes each per year in Labor & Delivery and Aftercare for new-borns

2. Hold 40 orientation sessions throughout the year for approximately 10 to 12 patients each time.

1. Education through the orientation and classes on the appropriate use of com-munity resources including the clinic, OB Team, The Med, ER, etc.

1. Hold 40 orientation sessions throughout the year for approximately 10 to 12 patients each time.

OB Nurse & Pediatric Nurse

OB Team

OB Team

OB Team

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