228229Enhanced Care Services and Health Homes

ALISHA H. WILKES AND JILL ALLIMAN

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

1.  Define enhanced care services (ECSs) in relation to midwifery-led care at freestanding birth centers in the United States

2.  Describe elements of ECSs currently offered by freestanding birth centers in the United States

3.  Describe elements of the patient-centered medical home (PCMH) model that are common to the freestanding birth center model

4.  Explain ways in which freestanding birth centers can meet the diverse needs of health care consumers in the United States

Despite advancing technologies and increased spending in the United States, the needs of women and families, particularly in maternity care, are not being met (WHO, UNICEF, UNFPA, the World Bank, and United Nations Population Division Maternal Mortality Estimation Inter-Agency Group, 2013). For example, from 2000 to 2012 the maternal mortality rate in the United States increased from 13 per 100,000 to 15.9 per 100,000 (Centers for Disease Control and Prevention [CDC], 2016). Improved models of health care delivery are needed to better meet the needs of health care consumers. The federal Affordable Care Act (ACA) has called for the implementation of collaborative, integrated models of health care delivery (U.S. Department of Health and Human Services [USDHHS], 2014). The PCMH model, birth center model, and midwifery model of care have been shown to decrease health care costs, improve outcomes, and improve 230patient satisfaction (Neilson, Langner, Zema, Hacker, & Grundy, 2012; Sandall et al., 2013). Adapting and blending elements of the freestanding birth center models and PCMH models provides an opportunity to create a synchronistic, sustainable model, better equipped to provide evidence-based care and improve outcomes. Although there is little data available, we explore the integration of ECSs and collaborative, integrated care with the freestanding birth center model and propose such a model.

ENHANCED CARE SERVICES

ECSs are defined as those services beyond the scope of standard midwifery-led maternity care most often provided in freestanding birth centers (Wilkes, 2015). Services such as mental health, men’s health, pediatric care, nonpregnant women’s health, and some maternity services, including ultrasound and genetic testing/counseling, may be considered ECSs. Standard midwifery-led maternity care generally includes prenatal, labor and birth, newborn, and postpartum care, although the scope and details of these services vary. The scope of midwifery-led maternity care differs from state to state and depends on the type of midwife providing services and the individual state laws. Professional organizations outline scope of practice for their membership, including the American College of Nurse-Midwives (ACNM, 2011), the National Association of Certified Professional Midwives (NACPM, 2014), and the American Association of Birth Centers (AABC, 2016).

ENHANCED CARE SERVICES IN FREESTANDING BIRTH CENTERS

As of 2015, no data were available regarding services provided by freestanding birth centers beyond the scope of standard midwifery-led maternity care (Wilkes, 2015). In order to determine if birth centers could function as health homes and/or collaborative, integrated health centers, several questions needed to be answered:

231In order to begin addressing these questions, this author (Dr. Alisha H. Wilkes) conducted an online survey of freestanding birth centers in the United States (Wilkes, 2015). Elements of this survey and discussion of its implications are presented.

About the Survey

An in-depth literature review revealed no relevant articles or research regarding ECSs offered by freestanding birth centers or linking freestanding birth centers and the PCMH model. A web engine search for “primary care at freestanding birth centers” resulted in five relevant links to birth centers providing some type of care beyond maternity services. Information from these websites indicated that freestanding birth centers were likely providing some types of ECSs and that there was a need to gather data regarding the services provided.

An online survey consisting of 63 questions covering freestanding birth center demographics and funding, patient demographics, and various types of services was created. A list of 301 known freestanding birth centers in the United States was obtained from the AABC. An introductory letter containing a link to the online survey was sent to the 267 with e-mail addresses included in the AABC list. Twenty-five e-mails were returned undeliverable, leaving a total of 242 e-mails assumed to have been delivered. Forty-eight freestanding birth center representatives began the survey and 45 finished the survey, resulting in a 19.8% response rate and a 93.7% completion rate of those who responded. Respondents were able to skip questions as desired and many questions allowed for multiple responses. Institutional review board (IRB) approval was obtained and participating freestanding birth centers provided informed consent (Wilkes, 2015).

Survey Results

Freestanding Birth Center Demographics

Respondents were located in 20 states. Nine were in Texas; three were in each of Florida, Oregon, Utah, and Virginia; two in Alaska, California, Colorado, Idaho, Maryland, New Mexico, New York, and Washington State; and one was from each of Georgia, Minnesota, Montana, North Carolina, South Carolina, Wyoming, and West Virginia. The highest percentage of birth centers were located in suburban areas (44%) and the lowest percentage were rural centers (21%). Accreditation had been achieved by 56% of the centers, and 71% were state licensed (Wilkes, 2015). Eight percent of 232respondents identified their birth center as part of a larger organization, whereas 44% selected independent and 94% identified as collaborative organizations. One freestanding birth center identified as a federally qualified health center and one as a PCMH, whereas 13% were not-for-profit organizations, and 54% were for-profit. The majority indicated clients paid for services with private insurance or self-pay, whereas 7% indicated use of federal funding. Of the respondents, 55.8% accepted Medicaid, 25.6% accepted Medicare, and 32.6% accepted TRICARE. For all of the questions, respondents could select more than one answer (Wilkes, 2015).

Patient Demographics

Respondents were asked to indicate the income categories and ethnicities/races of the populations they served. The majority served moderate (84%) and low-income (59%) populations, followed by those below the poverty level (25%) and high income (23%). The majority of respondents served Caucasians (96%) followed by Hispanics (67%) and African Americans (64%; Wilkes, 2015).

Maternity Services Provider Types

Respondents were asked to indicate which types of providers offered maternity services at their freestanding birth centers and were able to select multiple provider types. Figure 10.1 shows the percentage of freestanding birth centers with certain provider types offering maternity services (Wilkes, 2015).

Enhanced Maternity Services

Respondents were asked if their freestanding birth center provided maternity services beyond the scope of standard midwifery-led maternity care. The following statement was provided to participants to describe ECSs:

It is possible respondents had differing interpretations of the scope of maternity care. More precise definitions of standard maternity care and ECSs in birth centers will assist researchers and policy makers in the future. Of the respondents, 70% indicated they provided some type of 233enhanced maternity services. Table 10.1 shows the percentage of freestanding birth centers offering certain enhanced maternity services; respondents were able to select multiple services.

FIGURE 10.1 Percentage of freestanding birth centers with certain types of maternity services providers.

CNMs (certified nurse-midwives) = 72.5%; CMs (certified midwives) = 10%; CPMs (certified professional midwives) = 40%; LMs (licensed midwives) = 40%; NPs (nurse practitioners) = 12.5%; FPs (family practice physicians) = 0%; OBs (obstetricians) = 5%; PAs (physician assistants) = 2.5%; NDs (naturopathic doctors) = 10%.

Enhanced Care Services

Of the respondents, 56% offered community resources, 52% offered women’s health services, 42% offered mental health services, 35% offered pediatric services, 30% offered adjunct/alternative health services, and 28% offered men’s health services. These services were not defined within the survey, leaving them open to interpretation by respondents. Tables 10.2 and 10.3 show the percentage of freestanding birth centers offering certain types of services and Table 10.4 shows the percentage of freestanding birth centers using certain types of alternative/adjunct service providers.

Sustainability and Profitability

Interestingly, most respondents indicated the majority of the ECSs they provided were sustainable and/or profitable. Enhanced maternity services, women’s health services, and adjunct/alternative health services were all indicated as sustainable and/or profitable by greater than 70% of 234respondents. More than 50% of respondents indicated pediatric and mental health services were sustainable and/or profitable. Neither sustainable nor profitable were specifically defined within the survey, so both were open to interpretation by respondents.

The fact that ECSs are regarded as sustainable and/or profitable is encouraging. For birth centers to reasonably and responsibly offer ECSs, the services need to be integrated into a functional business plan. Knowing that other birth centers have been financially successful in doing so is vital to this process.

Understanding the Survey and Its Implications

Results of this survey indicate birth centers are offering a wide array of services beyond standard midwifery-led maternity care. It is likely they 235are working to better meet the health care needs of the communities they serve via the addition of these services and perhaps improve the financial viability of the birth center model. As with so many undertakings, the results of this survey lead to further questions and possibilities. In-depth case studies of freestanding birth centers known to provide ECSs may provide important information regarding the development, sustainability, and feasibility of an expanded model of birth center care. Consumer forums and focus groups addressing the desires and expectations of freestanding birth center consumers, such as the types of services they desire, conditions that would cause them to choose ECSs at a freestanding birth center rather than at another location, and their feelings, thoughts, and opinions on ECSs offered by freestanding birth centers would provide valuable insights and information (Wilkes, 2015).

236

The survey had several strengths and limitations. Limitations included a relatively low response rate of 19.8% and allowing respondents to skip questions, making the survey user-friendly but creating challenges for data management. Another limiting factor was the lack of clear definitions of services (e.g., women’s health, alternative/adjunct, leaving the terms open to interpretation by respondents). Strengths included a 93.7% 237completion rate by respondents and the generation of data and information not previously available. Clearly there are freestanding birth centers providing services in addition to standard midwifery-led care in the United States. The survey represented the first step in understanding ECSs and their role in the freestanding birth center model of care.

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