NR 555 Week 7 Equity Intervention Proposal Example

Intervention Proposal: Booking the Postpartum Visit Before Discharge on Every Day of the Week, With a Nurse Call and Transport at Two Weeks, Aimed at the Scheduling Mechanism and Judged by Whether the Gap Shrinks

Student Name

College of Nursing, Chamberlain University

NR 555: Health Policy: Advancing Health Equity & Outcomes

Instructor Name

Month Day, Year

Intervention Proposal: Booking the Postpartum Visit Before Discharge on Every Day of the Week, With a Nurse Call and Transport at Two Weeks, Aimed at the Scheduling Mechanism and Judged by Whether the Gap Shrinks

The Mechanism Targeted

This proposal targets one of the mechanisms identified in the determinants write-up: postpartum visits being scheduled by patients calling the clinic after going home. That arrangement places the work of scheduling on new parents, and falls hardest on those with unstable phone service, less flexible work and less reliable transport, burdens that in this region weigh more on Black Medicaid enrollees. The equity-focused literature matrix also found that a local pilot of booking before discharge excluded weekend discharges, which may have widened the gap. The coverage mechanism has been addressed by the state's 12-month postpartum extension; this proposal addresses the scheduling mechanism that the extension does not reach.

The Intervention

The intervention has three parts, delivered at the three hospitals that handle most Medicaid births in the region.

Booking before discharge, every day. A postpartum scheduler, staffed seven days a week including weekends and holidays, books a postpartum visit for every Medicaid-covered birth before the patient leaves the hospital. The appointment is set at a clinic the patient chooses, preferably near home, within three weeks of birth for those with hypertension or other risks and within six weeks for others, consistent with guidance that postpartum contact should begin early (American College of Obstetricians and Gynecologists, 2018). The patient leaves with the date, time, address and a phone number in writing and by text.

A nurse call at about two weeks. A registered nurse calls each patient around day 10 to 14 to check on recovery, screen for warning signs including high blood pressure symptoms and depression, confirm the appointment and ask what might prevent attendance.

Transport on request. Patients who report no reliable transport are offered a ride through the Medicaid non-emergency transportation benefit, booked by the nurse during the call, with a car seat arranged.

Success Stated as a Gap

The primary outcome is the difference in postpartum visit rates between Black and white Medicaid enrollees, using the state's measure of a visit within 7 to 84 days. At baseline, that difference is 16 percentage points (58% against 74%). The intervention succeeds if the gap narrows to 8 points or less within 18 months. A rise in the overall rate with no change in the gap would not count as success, because it would mean the intervention helped everyone equally and left the inequity in place. An overall rise with a widening gap would count as failure.

Secondary outcomes are the gap between Hispanic and white enrollees; the share of Medicaid births with a visit booked before discharge, by race and by weekday versus weekend discharge; the share reached by the two-week call; and the number of rides provided.

The Split Fixed in Advance

The groups, outcome and direction are written down before the intervention starts: Black non-Hispanic and white non-Hispanic Medicaid enrollees, postpartum visit within 7 to 84 days, gap narrowing. Fixing this in advance prevents choosing, after the fact, whichever split looks best. The analysis will also report results by hospital and by discharge day, because weekend discharges were the group the earlier pilot excluded. Equity reporting guidance recommends specifying the groups and the intended effect on the gap before analysis (Welch et al., 2012).

Who Delivers It and What It Costs

Delivery requires about 2.8 full-time schedulers to cover all shifts across three hospitals, and 1.5 full-time registered nurses for about 5,000 two-week calls a year. At local wages, personnel costs are about $340,000 a year. Rides are covered by the existing Medicaid transport benefit. The managed care plans have an incentive to fund the program, because the postpartum care rate is part of their quality performance, and the state's quality program includes a disparity-reduction goal.

Timeline

The program would run in three phases. In the first three months, the hospitals hire and train schedulers and nurses, agree on a list of clinics accepting appointments and set up the text messaging and ride booking processes. From months four to sixteen, the program runs at all three hospitals, with monthly reports on booking rates by race and discharge day. In months seventeen and eighteen, the state's postpartum care data for the program period are analyzed against the baseline, and the result is reported whether or not the gap narrows. A mid-point review at month ten would check whether weekend discharges are being booked at the same rate as weekday discharges; if not, staffing would be adjusted before the final evaluation.

Why Scheduling First

Of the mechanisms identified, scheduling was chosen first for three reasons. It is within the hospitals' power to change without new legislation or funding streams beyond the plans. Its effect can be measured within 18 months. And the local pilot showed both its promise and its main failure, which this design corrects. Clinic closures and experiences of disrespect are important but slower to change: reopening clinics requires capital and staff, and improving respectful care requires training, accountability and patient-reported measures that the state does not yet collect. The proposal recommends that the state begin collecting respectful care measures now, so that a second intervention can be designed with data behind it.

Risks

Booking before discharge may produce appointments patients cannot keep if they are not asked about work, childcare and transport; the scheduler will ask. Some patients may prefer to schedule later; they can decline. The nurse call may not reach people whose phones change; the call will also be offered by text. And if the gap is driven mainly by experiences of disrespect, scheduling improvements will not close it. That is why the proposal measures the gap directly and will report if it does not narrow, rather than claiming success from an overall rise. Bailey and colleagues cautioned that interventions addressing access alone may leave structural causes untouched (Bailey et al., 2017), and the evaluation is designed to show if that is the case.

The proposal is deliberately narrow. It addresses one mechanism well and measures whether that mechanism was a large part of the gap. If the evaluation shows a narrowing, the model can be extended to other hospitals; if it does not, the state will know to look harder at the mechanisms the proposal set aside.

References

American College of Obstetricians and Gynecologists. (2018). ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology, 131(5), e140-e150. https://doi.org/10.1097/AOG.0000000000002633

Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389(10077), 1453-1463. https://doi.org/10.1016/S0140-6736(17)30569-X

Welch, V., Petticrew, M., Tugwell, P., Moher, D., O'Neill, J., Waters, E., & White, H. (2012). PRISMA-Equity 2012 extension: Reporting guidelines for systematic reviews with a focus on health equity. PLoS Medicine, 9(10), Article e1001333. https://doi.org/10.1371/journal.pmed.1001333