Staff mix of prenatal case management programs: Are nurses doing the work?

Prenatal case management (PCM), a community-based, health related service, is designed to improve birth and infancy outcomes for high-risk pregnant women. Research has demonstrated that PCM is effective when provided by registered nurses (RNs). Anecdotally, PCM programs employ case managers from various disciplines and with varying levels of education, who then manage cases of varying risk levels. This type of staffing mix is antithetical to the evidence-based RN model. Thus, as a first step toward understanding the use of evidence-based models, we sought to describe the actual staffing mix of PCM programs across the nation, as well as the client caseload size carried by staff and caseload severity.

Data available from an ongoing national survey of PCM programs were analyzed. PCM program directors (n=43), predominantly from local health departments (72%), provided information on each PCM employee, specifically their educational level, discipline, work roles, caseload, and client risk level. PCM programs employ an average of 3.9 full-time equivalents (FTEs; range = 0 to 18), of which 2.6 FTEs are RNs and 1.2 FTEs are social workers. Governmental organizations had higher FTEs for RNs compared to non-governmental organizations. On average, RNs carried a caseload of 19 cases (s.d.=13.84), with an average case risk level of 2.1 (s.d.= .79, using a 1 to 4 scale). In contrast, staff designated as case managers (CMs), carry an average caseload of 48 cases (sd = 86.11) and aides carry 14 cases (sd = 11.14). The average case risk level carried by CMs and aides was no different from RNs. Compared to aides, CMs have three times as many cases per hour and RNs have twice as many. Client risk level differed by CM education level (F=7.9; p<.001); CMs with higher educational attainment generally had cases with higher severity.

The results suggest that an interdisciplinary model of PCM is in use, rather than the strictly RN model. The seemingly low extent to which an evidence-based model is used raises the possible need for state and federal policy regarding staff mix. Further studies need to compare the effectiveness of the different staff mix models of PCM.