Notes from the Field
Editor's Note: Submissions to Notes from the Field (500-1000 words) should be sent to Hugh H. Tilson, MD, Director, Epidemiology, Suwveilance and Pharmaco-economics (ESP) Division, Burroughs Wellcome Co., 3030 Comwalis Road, Research TnangleParl, NC27709. This colwnn presents information regarding newsworthy public health programs and project experience at the cormmuity level. Further infonnation should be sought from the person(s) listed in the footnote to each article.
MOM-Mobile Brings Ultrasounds to Moms Indianapolis, Indiana, had the highest mortality rate among Black infants of anymajor United States city in 1984, 1986, and 1987. In January 1989, the Infant Mortality Task Force appointed by the CityCounty Council presented a report which identified contributing factors and described action plans and strategies to reduce infant mortality in high-risk neighborhoods. Indianapolis has a metropolitan population of 1.2 million and about 13,000 births each year, of which 26 percent are Black. Lack of comprehensive prenatal care was cited as a major contributing factor; less than one-third of all Black women in the community were receiving adequate prenatal care. The Task Force report called for removal of barriers to access, expansion of the prenatal system capacity into unserved areas of need, and improved outreach, education, and support through community-based care coordination. With partial funding from the city, plans to expand the system capacity included adding three new prenatal clinic sites. However, funding was not available to provide ultrasound examinations at ei-
August 1991, Vol. 81, No. 8
ther the existing or new clinics. Since each clinic site provides prenatal care only one or two days a week, equipment costs of about $80,000 per ultrasound unit are prohibitive. Thus the idea for a mobile unit was born, supported by a prominent board member of the National March of Dimes. The vehicle, a 35-foot long motor coach, was purchased by the Indianapolis Foundation. Additional funding to support the Maternity Outreach Mobile (MOM) Project was raised by the local March of Dimes through contributions from local organizations, foundations, and businesses to the previously established Charlene S. Lugar Birth Defects Grant Fund. The vehicle was customized to include a reception area, a functioning bathroom, and two examination rooms, one of which is equipped with an ultrasound machine. Title to the vehicle was transferred from the March of Dimes to the Indiana University Board of Trustees. Initial capital expenses of $170,000 included purchase of the vehicle ($65,000), equipment and remodeling ($25,000), and the ultrasound machine ($80,000). An additional $39,000was spent on administrative expenses which included computer hardware and software and the salary of the coordinator for the first year. The annual operating budget of $80,000 includes salaries ($66,000), supplies ($3,500), and maintenance, fuel, and insurance for the vehicle ($10,500). The MOM Project is managed by Indiana University School of Nursing. This association with the university provides professional liability coverage for all project employees and established channels for personnel, purchasing, legal review, and a variety of other services. A strong relationship has developed between the School of Nursing and the Indiana University School of Medicine Department of Obstetrics and Gynecology. Although
funded by the MOM Project, the MOMmobile ultrasonographer is a member of the OB/GYN Department ultrasonography team. This relationship provides supervision and backup coverage for the MOM-mobile ultrasonographer. Physicians from the OB/GYN Department interpret all ultrasound results. Through a contractual agreement with the Marion County Health Department, ultrasound services are provided at each of the seven prenatal clinic sites located in high-risk neighborhoods. Staggered schedules permit one vehicle to serve all clinics over a two-week rotation. Appointments are made by prenatal clinic staff upon referral from a Health Department physician. To assure continuity of care, ultrasound examinations are done during the prenatal clinic visit with follow-up by the clinic staff. As soon as an examination is completed, the clinic receives a preliminary report and the pregnant woman usually receives a copy of a picture taken during the exam. Within 48 hours, the ultrasonographer transmits the information to the OB/GYN Department physician who interprets the findings and sends a final report back to the prenatal clinic. Previously, the Health Department referred prenatal patients to the county general hospital for ultrasound examinations. Transportation and other access barriers contributed to a 60 percent failed appointment rate. In its first nine months of service, the MOM-mobile performed 1,156 ultrasound examinations; 86 percent of available appointments were scheduled and the failed appointment rate was reduced to 13 percent. The MOM-mobile has beenveryweli received by both program participants and the staff at Health Department prenatal clinics. In response to requests from other community health center clinics which are Amencan Journal of Public Health 1073
Notes fm the Fldd
not part ofthe Health Department system, the project plans to expand service to include three more sites. Success can be attributed to three factors: 0 The project started with a conceptually strong design, adequate financial backing, and sufficient staff support. The service plan was in direct response to identified needs. During the development phase, plans were reviewed by key individuals and modified as needed. March of Dimes financial support has allowed the project to provide quality care until Medicaid expansion establishes a reliable revenue stream. The actual ultrasound component can be self-sufficient at the current rate of Medicaid reimbursement in Indiana. The project coordinator who arranged extensive remodeling of the motor vehicle before services began, now schedules routine maintenance and repair of equipment, and responds quickly as unanticipated problems occur. Working relationships with the clinic staff at various sites and Health Department administrators are nurtured through prompt attention to issues that arise and by being easily
1074 American Journal of Public HealthA
accessible and available at the sites as services were developed. * The MOM-mobile itself is strikingly attractive. Initial concerns by some health professionals about lack of privacy have been dispelled. Parked adjacent to the clinic, the MOM-mobile functions as an extension of that facility. The vehicle attracts attention from neighborhood residents and the media and has become a visible symbol of infant mortality reduction efforts. At night the MOM-mobile is parked on the property of a garage which provides preventive maintenance and, if needed, overnight or over-the-weekend repair. Only 2 percent of patient appointments have been rescheduled due to mechanical problems with the generator, the vehicle itself, or the ultrasound equipment. * The staff is competent and caring. The driver doubles as receptionist, so patients are greeted by a friendly face when they enter. Paperwork is completed with a minimum of effort. Enough time is allocated per patient so the ultrasonographer can explain the procedure, identify distinguishing features of the fetus on the screen and in the photo the expectant mother re-
ceives, and reinforce the importance of proper nutrition and avoiding drugs, tobacco, and alcohol. If the patient wants, family members or close friends who accompany her to the clinic are encouraged to observe the ultrasound examination. Spontaneous statements of "feeling closer to the baby now that I've seen it" often are expressed. Referrals for more extensive ultrasound examinations are expedited by linkages which the ultrasonographer has developed with the clinic staff and OB/ GYN Department physicians, and by the mobile phone located on the MOM-mobile. The MOM-mobile is a contemporary model of mobile clinic services which have been used to increase access to care for the past 20 years. Further information, including plans and specifications, is available upon request to the author.
Prpared by: Joanne B. Marin, DrPH, RN, Project Director, and Michael J. Finwery, MOM Coordinator, Matemity Outreach Mobile (MOM) Project, Indiana Unives* School ofNwsuing Room 238, 1111 Middle Dive, In-
dianapolis, IN46202-5107. TeL 317/274-4419or
274-3837
August 1991, Vol. 81, No. 8
Editor's Note: Submissions to Notes from the Field (500-1000 words) should be sent to Hugh H. Tilson, MD, Director, Epidemiology, Suwveilance and Pharmaco-economics (ESP) Division, Burroughs Wellcome Co., 3030 Comwalis Road, Research TnangleParl, NC27709. This colwnn presents information regarding newsworthy public health programs and project experience at the cormmuity level. Further infonnation should be sought from the person(s) listed in the footnote to each article.
MOM-Mobile Brings Ultrasounds to Moms Indianapolis, Indiana, had the highest mortality rate among Black infants of anymajor United States city in 1984, 1986, and 1987. In January 1989, the Infant Mortality Task Force appointed by the CityCounty Council presented a report which identified contributing factors and described action plans and strategies to reduce infant mortality in high-risk neighborhoods. Indianapolis has a metropolitan population of 1.2 million and about 13,000 births each year, of which 26 percent are Black. Lack of comprehensive prenatal care was cited as a major contributing factor; less than one-third of all Black women in the community were receiving adequate prenatal care. The Task Force report called for removal of barriers to access, expansion of the prenatal system capacity into unserved areas of need, and improved outreach, education, and support through community-based care coordination. With partial funding from the city, plans to expand the system capacity included adding three new prenatal clinic sites. However, funding was not available to provide ultrasound examinations at ei-
August 1991, Vol. 81, No. 8
ther the existing or new clinics. Since each clinic site provides prenatal care only one or two days a week, equipment costs of about $80,000 per ultrasound unit are prohibitive. Thus the idea for a mobile unit was born, supported by a prominent board member of the National March of Dimes. The vehicle, a 35-foot long motor coach, was purchased by the Indianapolis Foundation. Additional funding to support the Maternity Outreach Mobile (MOM) Project was raised by the local March of Dimes through contributions from local organizations, foundations, and businesses to the previously established Charlene S. Lugar Birth Defects Grant Fund. The vehicle was customized to include a reception area, a functioning bathroom, and two examination rooms, one of which is equipped with an ultrasound machine. Title to the vehicle was transferred from the March of Dimes to the Indiana University Board of Trustees. Initial capital expenses of $170,000 included purchase of the vehicle ($65,000), equipment and remodeling ($25,000), and the ultrasound machine ($80,000). An additional $39,000was spent on administrative expenses which included computer hardware and software and the salary of the coordinator for the first year. The annual operating budget of $80,000 includes salaries ($66,000), supplies ($3,500), and maintenance, fuel, and insurance for the vehicle ($10,500). The MOM Project is managed by Indiana University School of Nursing. This association with the university provides professional liability coverage for all project employees and established channels for personnel, purchasing, legal review, and a variety of other services. A strong relationship has developed between the School of Nursing and the Indiana University School of Medicine Department of Obstetrics and Gynecology. Although
funded by the MOM Project, the MOMmobile ultrasonographer is a member of the OB/GYN Department ultrasonography team. This relationship provides supervision and backup coverage for the MOM-mobile ultrasonographer. Physicians from the OB/GYN Department interpret all ultrasound results. Through a contractual agreement with the Marion County Health Department, ultrasound services are provided at each of the seven prenatal clinic sites located in high-risk neighborhoods. Staggered schedules permit one vehicle to serve all clinics over a two-week rotation. Appointments are made by prenatal clinic staff upon referral from a Health Department physician. To assure continuity of care, ultrasound examinations are done during the prenatal clinic visit with follow-up by the clinic staff. As soon as an examination is completed, the clinic receives a preliminary report and the pregnant woman usually receives a copy of a picture taken during the exam. Within 48 hours, the ultrasonographer transmits the information to the OB/GYN Department physician who interprets the findings and sends a final report back to the prenatal clinic. Previously, the Health Department referred prenatal patients to the county general hospital for ultrasound examinations. Transportation and other access barriers contributed to a 60 percent failed appointment rate. In its first nine months of service, the MOM-mobile performed 1,156 ultrasound examinations; 86 percent of available appointments were scheduled and the failed appointment rate was reduced to 13 percent. The MOM-mobile has beenveryweli received by both program participants and the staff at Health Department prenatal clinics. In response to requests from other community health center clinics which are Amencan Journal of Public Health 1073
Notes fm the Fldd
not part ofthe Health Department system, the project plans to expand service to include three more sites. Success can be attributed to three factors: 0 The project started with a conceptually strong design, adequate financial backing, and sufficient staff support. The service plan was in direct response to identified needs. During the development phase, plans were reviewed by key individuals and modified as needed. March of Dimes financial support has allowed the project to provide quality care until Medicaid expansion establishes a reliable revenue stream. The actual ultrasound component can be self-sufficient at the current rate of Medicaid reimbursement in Indiana. The project coordinator who arranged extensive remodeling of the motor vehicle before services began, now schedules routine maintenance and repair of equipment, and responds quickly as unanticipated problems occur. Working relationships with the clinic staff at various sites and Health Department administrators are nurtured through prompt attention to issues that arise and by being easily
1074 American Journal of Public HealthA
accessible and available at the sites as services were developed. * The MOM-mobile itself is strikingly attractive. Initial concerns by some health professionals about lack of privacy have been dispelled. Parked adjacent to the clinic, the MOM-mobile functions as an extension of that facility. The vehicle attracts attention from neighborhood residents and the media and has become a visible symbol of infant mortality reduction efforts. At night the MOM-mobile is parked on the property of a garage which provides preventive maintenance and, if needed, overnight or over-the-weekend repair. Only 2 percent of patient appointments have been rescheduled due to mechanical problems with the generator, the vehicle itself, or the ultrasound equipment. * The staff is competent and caring. The driver doubles as receptionist, so patients are greeted by a friendly face when they enter. Paperwork is completed with a minimum of effort. Enough time is allocated per patient so the ultrasonographer can explain the procedure, identify distinguishing features of the fetus on the screen and in the photo the expectant mother re-
ceives, and reinforce the importance of proper nutrition and avoiding drugs, tobacco, and alcohol. If the patient wants, family members or close friends who accompany her to the clinic are encouraged to observe the ultrasound examination. Spontaneous statements of "feeling closer to the baby now that I've seen it" often are expressed. Referrals for more extensive ultrasound examinations are expedited by linkages which the ultrasonographer has developed with the clinic staff and OB/ GYN Department physicians, and by the mobile phone located on the MOM-mobile. The MOM-mobile is a contemporary model of mobile clinic services which have been used to increase access to care for the past 20 years. Further information, including plans and specifications, is available upon request to the author.
Prpared by: Joanne B. Marin, DrPH, RN, Project Director, and Michael J. Finwery, MOM Coordinator, Matemity Outreach Mobile (MOM) Project, Indiana Unives* School ofNwsuing Room 238, 1111 Middle Dive, In-
dianapolis, IN46202-5107. TeL 317/274-4419or
274-3837
August 1991, Vol. 81, No. 8
