Sunday, August 18, 2013

Maternity care plan

Midwives who are eligible to participate in Medicare, and offer Medicare rebates for women in their care, have this item in the Medicare schedule:

Item 82115
Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks, if:

(a) the patient is not an admitted patient of a hospital; and

(b) the participating midwife undertakes a comprehensive assessment of the patient; and

(c) the participating midwife develops a written maternity care plan that contains:

(i) outcomes of the assessment; and
(ii) details of agreed expectations for care during pregnancy, labour and delivery; and
(iii) details of any health problems or care needs; and
(iv) details of collaborative arrangements that apply to the patient; and
(v) details of any medication taken by the patient during the pregnancy, and any additional medication that may be required by the patient; and
(vi) details of any referrals or requests for pathology services or diagnostic imaging services for the patient during the pregnancy, and any additional referrals or requests that may be required for the patient; and

(d) the maternity care plan is explained and agreed with the patient; and

(e) the fee does not include any amount for the management of labour and delivery (Includes any antenatal attendance provided on the same occasion) Payable only once for any pregnancy

[Schedule 1 Part 1 of
Health Insurance (Midwife and Nurse Practitioner) Determination 2011]

It's clear from the legislation that a 'maternity care plan' is an important aspect of the antenatal care  provided by a participating midwife.  The professional attendance linked to Item 82115 is to take at least 90 minutes, and the scheduled fee is $319.00.  This compares with other antenatal attendances of at least 40 minutes, with a scheduled fee of $53.40.  Clearly, someone who advised the writer of this piece of legislation considered that the writing of a maternity care plan, and the other tasks (listed above) are very significant.

A midwife who has recently received her endorsement as an eligible midwife wrote to a social media site "I wonder if anyone could share their written maternity care plan format? Just want to know what you include and how to set it out ..."

This is a good question.  What does a maternity care plan look like?

It has occurred to me that the ICM Definition of the Midwife is a clear statement of a midwife's maternity care plan:

The midwife ...
is recognised as a responsible and accountable professional who
  • works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, 
  • to conduct births on the midwife’s own responsibility and 
  • to provide care for the newborn and the infant. 
This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The insurance company MIGA, in consultation with ACM and APMA, has developed a care plan that some midwives have adopted.  This care plan has a lot of boxes to tick, and much of the information would be collected routinely by midwives in taking a history and discussing care options with each woman.  Those who are using specially designed software would have many of the points of this care plan covered in entering the client information, and would be able to generate a maternity care plan printout when required.

The maternity care plan is to be kept with other professional records for each woman and baby, by the midwife.  The care plan usually does not need to be shared with anyone, unless asked for, for example, in a Medicare audit or an investigation.

There is ongoing discussion and concern about the relationship between midwives and public hospitals, particularly those hospitals that have, to date, refused to discuss any collaborative arrangements with midwives. MIGA states that, in order to meet the legislative requirements, a midwife is required to have:
  • A Collaborative Arrangement with a doctor or Hospital, or
  • A Care Plan communicated to a public Hospital providing obstetric services
    • You should ensure this is acknowledged by the Hospital either in writing or as a record in your notes of an oral acknowledgement

      We note here that midwives in Melbourne, and many other places, who have attempted to comply with this requirement of acknowledgment (written or oral) by a hospital have had no success.  The hospitals have, to date, not been interested in collaborating with midwives.  Some hospitals have returned care plans to the midwife, and instructed her not to send them.   This problem seems to be ongoing, as was discussed in a previous post on this blog.


      The MIGA maternity care plan seems to attempt to cover the 'what if' situations, in which a midwife might be required to defend her or his actions.  That makes sense - that's the job of insurance companies.

      But, ...

      Midwifery is not, primarily, about defensive practice.  It's about the midwife acting in a way that protects the wellbeing and safety of mother and baby.  It's about being 'with woman', in a special professional relationship.  It's about health promotion: healthy mothers and babies.  Midwives should not be instructed by an insurer, an entity that exists to make a profit for shareholders, as to the care plans they make.

      Midwives are encouraged to make a positive statement in each woman's maternity care plan, such as:

      "When providing primary maternity care for a well woman, the plan is to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise. If illness or complications are suspected, a transfer to the planned hospital would be arranged without delay for urgent obstetric concerns, ..."

Thursday, August 1, 2013

amended regulation

On July 25th 2013 the Health Insurance Amendment (Midwives) Regulation 2013 was introduced.
The purpose of this regulation is to enable midwives to have collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity.

This new regulation adds a new type of collaborative arrangement for an eligible midwife who is credentialed by a hospital, having successfully completed a formal assessment of her or his qualifications, skills, experience and professional standing.  At present processes exist with some public maternity services for midwives to be recognized as shared antenatal care affiliates.  It would seem reasonable to expect that these processes could be extended to meet the requirements for collaborative arrangements during intranatal and postnatal care as well as antenatal. 

Three years ago, in April 2010, the Health Insurance Act (1973) was amended to provide for new arrangements to enhance and expand the role of certain midwives, allowing for a greater role in the provision of quality health services through primary maternity care.  Since the measure was introduced, midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare arrangements, and has prevented some women from receiving Medicare rebates.  

Midwives who have achieved endorsement on the AHPRA Register of Midwives as Eligible (for Medicare and Prescribing) have achieved a high standard of clinical practice.  They have gone to considerable financial and personal cost, in complying with the requirements of the Board.  When a midwife is in private practice, with a Medicare provider number and a Prescriber number, that midwife has access to the most advanced model of clinical practise in primary maternity care available to midwives in Australia.

A few midwives participating in Medicare have a collaborative arrangement in the form of a signed agreement with an obstetric medical practitioner: an arrangement that applies to all women in their care.

Most midwives, however, require a separate collaborative arrangement for each woman in their care.  This is the reason many midwives have reported ongoing difficulties in establishing collaborative arrangements. Each collaborative arrangement needs to be requested, and negotiated separately.   

One of the options for collaboration is referral:
5 (1) (b) a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;

A general practitioner doctor (GP) who provides obstetric services, such as shared antenatal care, is able to act as a specified medical practitioner who refers a woman to an eligible midwife for midwifery treatment.  

Midwives who have received letters of referral, or other collaborative arrangements, from GPs or obstetricians, recognise that there have been areas of uncertainty and difficulty in establishing meaningful collaboration that meets the legislated requirements and is in the interests of the wellbeing of the mother and her baby.  Some GPs have expressed serious concerns about their liability, should there be an adverse outcome at some time in the future.  No amount of assurance by the midwife that she/he is accountable, and insured (except for homebirth) will satisfy a doctor if their insurer tells them not to take the risk of supporting midwives.

In recognition of the difficulties experienced by midwives in achieving collaborative arrangements, the government agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. This amendment to the regulations potentially takes the pressure off GPs, in that midwives will (theoretically, at least) be more able to establish collaborative agreements with hospitals.  The woman's GP will not be ignored, as there is a continuing requirement for a discharge letter, copies of any test and investigation results, and reports of referrals, to be sent to the GP.

MIPP is engaging in ongoing discussions with public maternity hospitals, in an effort to forge new pathways for credentialing by the hospitals for midwifery care that spans the full episode of care. 

Perhaps this amended regulation will be the impetus for progress in maternity hospitals that have, to date, been resistent to change.  The need for collaborative arrangements to be facilitated through the public maternity hospitals to which we refer women in our care is obvious.  The systems need to be seamless and transparent, protecting the wellbeing and safety of mother and child, as well as offering a reliable and accountable process for members of the midwifery profession, and for the hospital and its employees.

Your comments are appreciated.