Running head: PREGNANT TEEN CASE MANAGEMENT

Pregnant Teen Case Management Deborah Rafferty American Sentinel University Case Management BSN 440 Professor Karen Egenes July 30, 2012

PREGNANT TEEN CASE MANAGEMENT Pregnant Teen Case Management Teen pregnancy is a well known problem in the United States. There were over 409 thousand babies born in 2009 from teenage girls ages 15 to 19, the majority of these births were not intended. Although living in poverty, being from a single parent household, and having difficulty in school increase the chance of becoming a teen parent, it can happen in any socioeconomic neighborhood. Being an offspring to teen parents increases the chance by 33% that they will become teen parents as well ("About teen pregnancy," 2011). There are many problems associated with teen pregnancy. Each year teen pregnancies cost over nine billion dollars for the U.S. taxpayers. The money assists in the costs for increased health and foster care, increased incarceration rates

among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers("About teen pregnancy," 2011, p. 1). The health risks for these pregnant teens include high blood pressure, preterm labor, poor nutrition and anemia. Since the teen mom is less likely to seek prenatal care, the risks are even greater. These young mothers are also more likely to smoke, drink and have untreated STDs, all of which can have a negative effect on the unborn child ("Teen Pregnancy," 2011). Adolescent sexuality has been a major discussion for generations. The teens of today have started exploring at an earlier age. Girls are reaching puberty earlier, oral sex is on the rise, uncertainty about sexual orientation is increased and about half of high school students have reported having sex. Although condom use has increased it has not stopped the rise of STDs. It is reported that 1 in 4 teens have been infected with human papillomavirus, Chlamydia, herpes, or trichomoniasis. As adolescents struggle to understand their emerging sexualities within the context of complex social environments, the challenge for health care providers is to provide

PREGNANT TEEN CASE MANAGEMENT adolescents with the necessary anticipatory guidance to maintain optimal sexual health and to help adolescents avoid behaviors that place them at risk for having negative consequences of their sexual behaviors and expression (Garofalo & Forcier, 2011, p. 1). To decrease the teen pregnancy rate, programs need to be developed so that teens will attend and understand. The National Campaign to Prevent Teen and Unplanned Pregnancys

suggests educating teens in being responsible for their actions by using contraception and taking the consequences of having sex seriously is a national priority. This campaign works with policy makers and the media to influence the need to educate teens on the affect of what the implications are in having a child in their teens. Their website assists teens, parents, the media and policy makers with the latest research on teen pregnancy and how to encourage teens on making the best choices about their sexual behaviors (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2012). For the teens that become pregnant having a program to ensure they are receiving the proper prenatal care that is essential for the wellbeing of their baby and themselves. Without prenatal care the teens that have any pre-existing conditions such as HIV/AIDS, high blood pressure, STDs, diabetes, or any health issues involving heart, lungs, or kidneys, they are putting themselves at risk as well as their babies. Equally as detrimental can be conditions that can occur during a pregnancy, including preeclampsia and gestational diabetes. Other high risk issues are preterm labor, multiple births, placenta previa and fetal problems ("Managing High-Risk Pregnancy," n.d.). If any of these conditions are present, being under the watchful eye of a doctor will decrease the chance of a poor outcome. The major direct causes of maternal morbidity and mortality include ("Maternal Health," 2011, p. 1) hemorrhage, embolism, infection, high blood pressure, cardiomyopathy

PREGNANT TEEN CASE MANAGEMENT unsafe abortion, and obstructed labor, even though 90% of deaths (Allender et al., 2010, p.

566) are preventable with prenatal care. The underlying cause of these fatalities can be related to any number of risk factors listed above as well as teen pregnancy and living in poverty. With proper intervention from healthcare professionals, most of these women would have a healthier pregnancy and newborn. Nutrition is another issue for the pregnant women especially for teens. Eating healthy during pregnancy benefits both the mother and the unborn baby ("ACOG Nutrition in Pregnancy," 2011). Increasing calories to assist with the healthy growth of the baby may be easy for some, yet others in low income areas may find this task unobtainable. Teens are at high risk of eating unhealthy, drinking, smoking and taking drugs which can account for babies being born premature or low birth weight ("Teen Pregnancy," 2011). Reducing maternal deaths and improving maternal health provide many benefits ("Maternal Mortality," 2006, p. 1). Some of the benefits of improving the health of women are: increasing their productivity in the home and in society, assisting with unplanned pregnancies and its possible financial hardship on the family, assisting the children of women who die during childbirth so that they may lead a productive life. The goal is to reduce the burden on women associated with frequent pregnancies, poor maternal health, pregnancy complications, and caring for sick children drains their productive energy, jeopardizes their income-earning capacity, and contributes to their poverty ("Safe Motherhood," 2011, p. 1). Pregnant teens would benefit from programs in their neighborhoods that assist them every step of the way of their pregnancy and even after. A case management program would be a nurse driven program, family focused, using evidence based practice to coordinate the care of a comprehensive interdisciplinary team (Finkelman, 2011). This team would assist the teens in

PREGNANT TEEN CASE MANAGEMENT improving their health while they are pregnant to increase their productivity in the home and in society and find them programs to assist with the cost of their pregnancy. The team goal is to reduce poor maternal health and pregnancy complications to reduce the risk of an unhealthy newborn. When the teen is caring for a sick child it decreases their productive energy,

jeopardizes their income-earning capacity, and contributes to their poverty ("Safe Motherhood," 2011, p. 1). The team members that would be beneficial to this program should consist of an Obstetrical practitioner, nutritionist, pharmacist, social worker and maternity nurses. The practitioner would be in charge of the medical prevention and care the teen would receive. A teen is at risk for poor nutrition, a nutritionist would assist the teen to make healthier food choices. The pharmacist would be able not only be able to assist the teens getting their prenatal vitamins but answer questions about any of the medications the patient may already be taking. Breastfeeding is of concern when a patient is on a high risk medication. Being a teen and pregnant has many implications that would make a social worker a very important team member. The social worker would be most affective with the psychosocial aspect of the teens care (Finkelman, 2011). It would be especially useful if the teen decided to give the baby up for adoption. Patients reap the benefits of more eyes and ears, the insights of different bodies of knowledge, and a wider range of skills (Wagner, 2000, p. 1). Each member brings their own specialty that will assist in the treatment plan for the teens. A nurse is perfect for heading up such a team. A nurse that is experienced and trained in maternity has the knowledge to start a population based care program. This plan starts with guidelines and defines the treatments. The nurse case manager can assess each teen and refer them to the other members when warranted.

PREGNANT TEEN CASE MANAGEMENT There have been many examples in literature that testifies the most successful programs have a nurse with experience in that field (Wagner, 2000).

Although the best scenario would be to prevent teen pregnancy, when it occurs, programs should be available in every community to decrease poor outcomes. The impact of Prenatal Care Coordination can be enhanced through increased outreach, strengthened relationships, and customized interventions for pregnant women and their families (Van Dijik, Anderko, & Stetzer, 2011, p. 101). And last but not least, increasing the positive outcomes of teen pregnancy will decrease the hardship the community will encounter because of them. The reason for having a case management program for pregnant teens is to improve the health and welfare of the both the mother and the child. Theses well orchestrated programs should be delivered as a combined care plan that may include prenatal care, reducing substance abuse, getting an education, job training, and getting referrals to community resources (Van Dijik et al., 2011). The programs can start in the schools or directly in the community. Best Practices In order to have successful programs the, case managers have to be flexible, be able to understand their patients concerns, and work with them on their priorities ("In-home case management," 2012, p. 29) or they will fail. Dealing with teenagers the case manager has to be aware of their confidentiality rights and to be respectful about their beliefs, whether it is religious, ethical, or their sexual preference (Alford, 2009). Focusing on the teens strengths instead of the weaknesses can increase their self esteem and keeping the communication at the teens level, being honest and trustworthy will increase the receptiveness of the programs (Metro Council for Teen Potential [MCTP], 2009). Published Guidelines

PREGNANT TEEN CASE MANAGEMENT In September 2009 the National Association of County & City Health Officials (NACCHO) put out a report called Meeting the Needs of Pregnant and Patenting Teens: Local Health Department Programs and Services. The three programs highlighted in this report

exhibit the components of highly successful programs for pregnant and parenting teen (National Association of County & City Health Officials [NACCHO], 2009, p. 17). These programs are from counties located in California, Maryland, and Minnesota. The Adolescent Family Life Program, from San Mateo County Health System and Santa Cruz County Health Department has similar programs that focus on the promotion of health awareness of the mother and child. Case managers arrange for home visits that focus on not only on health but the importance of education, housing, and assisting them in finding local resources. Both of these programs have seen high childhood immunization rates of children in the program (97 and 90 percent, respectively), low numbers of preterm and low birth weight infants born to program participants, and significant percentages of program clients who are enrolled in school (NACCHO, 2009, p. 9). Montgomery County Department of Health and Human Services in Maryland has a program that takes place either in the school or from visitations when the student is unable to go to school. This program concentrates on improving self esteem, teaching students how to identify and express feelings, and providing education, information, and opportunities for discussion (NACCHO, 2009, p. 10). The impact of this program has kept the repeat pregnancies down while emphasizing the importance of graduating high school. Minnesotas St. Paul-Ramsey County Department of Public Healths program also uses home visitations that run from the time they enter the program until the nurse and teen agree to end the visits. The impact of this program was to increase the graduation rates thus increasing the

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ability for the teen to get a job. Since the program required the teen to attend school to participate in the program, attendance was increased. The teen not only gets assistance with their health care needs but they also have a program to train them in becoming a nursing assistant, drivers education, furniture vouchers and assistance filling out forms for college (NACCHO, 2009). Clinical Pathways The common goals for these programs are to increase the graduation rate, increase prenatal care, assist with parenting skills, find jobs, have the teens become independent, and to decrease the likely hood of having subsequent teen births (NACCHO, 2009) (MCTP, 2009). Developing clinical pathways will spell out the care process with expected outcomes and interventions so that the interdisciplinary team can use it to coordinate care (Finkelman, 2011, p. 159). The team uses the best evidence based practice to reach the patients goals in a timely and costly manner (Finkelman, 2011). All of the above programs offer home visitation so that the teen does not have to worry about transportation. This allows the visiting nurse one on one time to assess the individuals needs, the living arrangements, and gives the nurse the needed time to build a trusting relationship. The visiting nurse evaluates the need for community services and assists them in getting the referrals if needed. Education is also a major focus for these programs (NACCHO, 2009), both in teaching the needed skills and in the teen finishing school. Studies have shown the importance of prenatal care; it can reduce the risk of preterm infants, kidney infections, preeclampsia, anemia, increase use of prenatal vitamins, proper weight gain and increase use of available community services (Van Dijk et al., 2011). The nurse case managers goal is to help enable the teen to become independent in taking care of themselves and their baby.

PREGNANT TEEN CASE MANAGEMENT There was a study conducted in Wisconsin comparing the women on Medicaid that

participated in a Prenatal Care Coordination (PNCC) program and those that did not. Out of the 45,406 Medicaid participants in 2001-2002, about 23 % participated in this program; 22% were teenagers. This managed care program had a nurse in charge of the initial assessment that focused on the mothers background, housing, and past medical and surgical history. The case manager together with the social worker, dietician and nurse came up with a plan of care that was mutually agreed upon with the mother. Physicians and teachers were also available for consultation if needed. It was found that the mothers that participated had reduced the unfavorable birth outcomes. The risk of having a low birth rate baby was down by 16% and the rates decreased by 22% for having a baby with very low birth weight. This program also decreased the chance of having a preterm baby and a baby that is transferred into the neonatal intensive care unit by 17%. Since infant mortality is increased with low birth rate babies the researchers suggested that the long term studies of this program would decrease the infant mortality rate (Van Dijk et al., 2011). Although the programs face challenges with funding, if they educate the community on the benefits of their pregnant teens graduating and becoming contributing adults in society, they may find a way to find the money to continue with these programs (NACCHO, 2009). These programs should be delivered within a comprehensive, broad-based community system of care for families and young children to insure the greatest long-term outcomes for creating a healthy population (Van Dijk et al., 2011, p. 107). Breaking the cycle of babies having babies would be beneficial to the entire community. The assessment begins the moment you receive the information about the patient. This usually includes the demographics, medical history, and if it pertains, a drug and physical

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history. This information is needed to form the framework and collect the necessary data to begin the assessment process (Willis, 2003). Assessment Economics Vignette: Lisa X (fictitious name), age 17 is a single pregnant teen. She is from Upper Darby, Pennsylvania. Lisa went to the local Planned Parenthood near her home and confirmed her pregnancy; that is where the referral originated. She had just finished 11th grade at the local public high school and lives with her mother and two younger siblings. Lisa has been with her boyfriend for two years and plans to stay with her mother until she is finished high school. She has no passed medical history, has no history of drug use or physical abuse, and her only surgery was a tonsillectomy at age 5. Lisa arrives alone and a few minutes early for her appointment. She is 57 and weighs 120 pounds; she states she has not gained any weight so far in her 16 week pregnancy. Her clothes are clean and she is dressed appropriately for her age; she has a small bump in her abdomen. The introductions were finished and the questions begin. After she confirms the information that was on her referral, the rest of her history was obtained.

Health This assessment ascertains her health history, medications, nutritional needs, psychological status, social issues, cultural or religious beliefs, education needs, and financial status (Finkelman, 2011). Lisa has a past history of anorexia, she only takes Tylenol for an occasional headache, does not practice any religion, needs education on her pregnancy as well as being a parent, and is on her mothers medical insurance at the present time. Lisas mother works

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two jobs; this leaves Lisa in charge of taking care of her 8 year old and 9 year old siblings. The first decision Lisa had to make was choosing an Obstetrical Practitioner. After reviewing her options, she selected the midwives office located in walking distance to her home. Obtaining additional information may be warranted, getting consent from the patient is necessary. Lisas pediatrician, mother, teachers, and school nurse may have valuable information on her academic, social, health and financial needs (Willis, 2003). It is noted that Delaware County does not presently have a Health Department even though it is the largest county in Pennsylvania (The Working Group for a Delaware County Health Department, 2011). There is a Planned Parenthood approximately twenty minutes from the high school, with public transportation available. This office is a great start for the pregnant teen, not only can they find out if they are pregnant but this office can assist the teen in applying for medical assistance if needed (Planned Parenthood, n.d.). Fortunately for some of the teens they are still covered under their parents insurance. Another asset for the pregnant teens in this area is the Midwives of Delaware County. Their office is located approximately 10 minutes from the high school and offer delivery at Delaware County Memorial Hospital which is located next to the high school. The Midwives office provides care before, during and after delivery. There are Obstetrical Doctors at this hospital as well; if the teen would prefer a physician (Crozer Keystone Health System, 2012). There are two programs in this area that are run by the Delaware County Intermediate Unit the Teenage Pregnancy and Parenting Program and the Education Leading to Employment and Career Training Program (Hardy, 2001, p. 1). The Delaware County Intermediate Unit (DCIU) is a regional education services agency (Delaware County Intermediate Unit, n.d, p. 1) and it is their mission to provide leadership for the development of

PREGNANT TEEN CASE MANAGEMENT innovative and cost-effective programs to meet the needs of our country (Delaware County

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Intermediate Unit, n.d, p. 1). This nurse can contact them to ask for assistance with this program.

Psycho-Social Situations When assessing the socioeconomic needs of Lisas community, the U.S. Census estimates for 2008 (Sept., 2009) reveal a poverty rate of 20% for children under 18 years of age in Upper Darby Township (Upper Darby School District, 2011, p. 1). This community is also a very diverse population: 42% African, 41% White (non-Hispanic), 13% Asian/Pacific Islander, 3% Hispanic and 1% Other (Upper Darby School District, 2012, p. 1). There is also 773 immigrants and refugees who are English learners (Upper Darby School District, 2012, p. 1). The teen birthrate in Delaware County as per the County Health Rankings is 23 out of 1000 females aged 15 to 19, which is about 3,438 a year. There are approximately 16,770 children in this county between the age of 5 and 18 (County Health Rankings, 2011). In 2007, Delaware County had 851 reported pregnancies to teens 19 and under (Delaware County Teen Pregnancy Prevention Coalition, n.d., p. 1) and in 2008 there were 529; of those 529, 105 were not the first pregnancy (Delaware County Teen Pregnancy Prevention Coalition, n.d, p. 1). Searching the internet for the locations of the nearest agencies was the next step for this patient. The next appointment was the home visit which assessed if her basic needs were being met, safety issues, health issues, siblings, and closest adult in case of an emergency. The patient was also asked how she planned on obtaining the necessary baby equipment. Information was also given on the role the boyfriend was going to play, financially as well as emotionally. All of the information obtained will assist in formulating a plan of care for the patients needs, support, strengths, challenges and resources (Willis, 2003).

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The home visits findings were appropriate. The 2 bedroom house her mother was renting was clean, neat, running water, electricity and there were no apparent safety issues. There were no signs of baby equipment. Lisas siblings were the typical 8 and 9 year olds, watching cartoons, while her mother was getting ready to leave for her second job. Her mother expressed concern about Lisas nutritional health, as she has had anorexia in the past. Lisa seemed to have a great relationship with her siblings and was polite to her mother. Joey, the boyfriend was not permitted in the house while her mother was working, a rule they admitted was broken a few times after the children were put to bed. There is enough information to create a plan of care using the patients goals, objectives, and a time line that is attainable and realistic. Plan of Care The first goal would be for Lisa to get her first pre-natal visit with the midwife of her choice. The appointment should be scheduled by tomorrow because Lisa should have made this appointment when she found out she was pregnant ("Your first," 2011). Prenatal care is the most important factor in having a healthy mother and child. At these prenatal visits the mother is tested for any conditions or disorders that need to be treated during her pregnancy and is given prenatal vitamins, folic acid and iron if needed. The vitamins make up for any deficiencies in the maternal diet; the folic acid decreases neural tube defects and iron is for anemia ("Ready for Pregnancy," 2011). The midwife will become an intricate team player in Lisas plan of care. Since nutrition is very important in pregnancy and both Lisa and her mother have verbalized concerns, this is the second goal in her care plan. Lisa will learn healthy eating habits to maintain the appropriate weight gain. Eating healthy during pregnancy benefits both the mother and the unborn baby ("ACOG Nutrition in Pregnancy," 2011). Increasing calories to assist with the healthy growth of the baby may be easy for some, yet teens with eating disorders

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may find it difficult. Even without an eating disorder, teens are at high risk of eating unhealthy, drinking, smoking and taking drugs which can account for babies being born premature or low birth weight ("Teen Pregnancy," 2011) ("Risks and Realities," 2010). Normal weight gain is 25 to 35 pounds during your pregnancy; this means you can gain 2 to 4 pounds in the first trimester and then one pound a week for the rest of your pregnancy ("Health & Pregnancy," 2010). A nutritionist will be consulted to determine whether she has reached this goal by the end of her third trimester and then every week until she delivers. Having Lisa keep a diary of food intake and the progress of her weight gain will give her some control over her nutrition. The third goal will coincide with her nutritional needs. Making an appointment with the Women, Infants & Children (WIC) program which provides supplemental foods and nutrition education to pregnant, postpartum and breastfeeding women, infants, and young children up to age 5 ("Delaware County Resource Guide," n.d., para. 3). This appointment should be made by the end of the week, as it will assist her with the essential food she will need. Goal number four will have to be discussed with her mother and her boyfriend. Lisa is presently on her mothers insurance, the baby will need insurance. If the boyfriend has a job and insurance, he can put the baby on his insurance. If he does not, Lisa will have to apply for emergency medical insurance for her newborn. If her baby is not eligible for Medical Assistance (MA) she will be referred to Pennsylvanias Children Health Insurance Program (CHIP). This program provides insurance for Pennsylvanias children and teens that are not eligible for MA (CHIP Pennsylvanias Childrens Health Insurance Program, n.d.). The time frame for this goal is by end of next month. The fifth goal is to make sure Lisa is ready for her senior year of high school. Her due date is January 5, 2013. If she delivers during winter break she may not miss any school,

PREGNANT TEEN CASE MANAGEMENT although child care will be an issue. This will be a tough goal for Lisa to accomplish; she will need to involve her counselor and school nurse to accomplish this goal. Since Lisa is the caregiver of her siblings she may end up being home schooled or cyber schooled. This goal would be to gather all of the information she needs to continue her education after the birth of her baby.

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Weekly meetings either in person or on the phone will allow the evaluation of the goals, the goals can be amended or new goals can be added (Willis, 2003). When Lisa is unable to make her prenatal appointments, sending a nurse to her home will keep Lisa on track to meet her goals. Assisting Lisa in obtaining baby items for free or at a discount would ease some of the burden on her family. During the evaluation and throughout the case, the case manager needs to make sure her health covers and her goals are being met (Finkelman, 2011). The ultimate goal of this case is to have Lisa deliver a health baby, obtain her high school diploma and become a contributing adult in the community. Referring Lisa to the local programs will increase her chance of success. When all of the goals are accomplished, Lisa can be discharged from care.

Implementing Using a framework from Healthy People 2020 called Map-it is great guide in implementing this program into the community. The acronym stands for mobilizing, assessing, planning, implementing and tracking. This framework starts with finding people that would want to have a health community ("Implementing Health People," n.d.). Mobilizing is looking for people to help with your program ("Implementing Health People," n.d.). Teen pregnancy is prevalent in this community. Finding people that believe it will

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be better for the community to assist pregnant teens in becoming healthier and better parents will appreciate the benefits of this program. Some of the potential stakeholders can be local government, schools, local businesses, religious groups, law enforcement agencies, community organizations ("Intro to program evaluation," 2006), doctors, midwives, social workers and nurses. The next step is assessing the communitys resources that will be useful for this program. Such resources in this community would be WIC, Planned Parenthood, Delaware County Memorial Hospital, The Delaware County Intermediate Unit which already has two programs that focus on pregnant teens (Hardy, 2001); these resources were mentioned under assessment. This assessment should be brainstormed by all of the involved members of this program, including the stakeholders ("Implementing Health People," n.d.). The planning step is when you have the details of the program worked out. The program will explain everyones role as well as a timeline for every step. Marketing the program is a part of the planning ("Implementing Health People," n.d.). Advertising in the community newspapers, hanging posters in local schools, businesses and community centers will help spread the word. Tracking is the last step in the implementation of this program. The tracking process in another way to evaluate the programs successes, failures and what needs to be improved. An outside data company may provide with unbiased evaluation. Releasing positive data to the community may bring in more help and stakeholders ("Implementing Health People," n.d.). Engage Stakeholders The reason to engage the stakeholders of this program is to gain their resources, networking, encourage local buy-ins, to understand the community, get assistance in decisionmaking, and to explore new ideas. Having stakeholders with different interests gives a wide

PREGNANT TEEN CASE MANAGEMENT range of information for the planning, organizing, implementing and evaluating stages of the program (The Robert Wood Johnson Foundation [FWJF], 2009). After choosing the potential

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stakeholders, then present the program with the statistics from the other programs that have been successful and what this program can do for this community. The key to keeping the interest of stakeholders is to get them involved from the very beginning. Allow the stakeholders to add their input, have deadlines for each goal, and be mindful of costs. Take into consideration that each stakeholder has their own agenda for what the outcome will mean (Cornett, 2010). For example a doctor may receive referrals for the prenatal care of the teens, whilst the Politian may get the votes from the younger generation. Key Outcomes Increase prenatal care Decreases morbidity and mortality rates ("Maternal Health," 2011) Decreases health risk from pre-existing conditions, such as, high blood pressure, preterm labor, poor nutrition, low anemia ("Teen Pregnancy," 2011) Decreased health risk from pregnancy related conditions, such as, gestational diabetes, preterm labor, preeclampsia, placenta previa, and multiple births ("Managing High-Risk Pregnancy," n.d.) Nutrition Needs Encourage healthy life style, including a healthy caloric intake, exercise, vitamins, and no smoking or drugs ("ACOG Nutrition in Pregnancy," 2011) Referrals to WIC office for nutritional needs for both mother and baby ("Delaware County Resource Guide," n.d.) Encouraging Education

PREGNANT TEEN CASE MANAGEMENT Increase high school graduation rates to decrease the cost to tax payers by

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decreasing health costs, foster care costs, incarceration rates and increase the lost revenue in the communities by encouraging teens to continue their education ("About teen pregnancy," 2011) Parenting Classes Decrease offspring from becoming teen parents by giving guidance to be self sufficient and to be good role models for their children ("About teen pregnancy," 2011) Although the number of teen pregnancies has decreased 44% from 1991 to 2010 it still costs well over ten billion dollars a year for tax payers (Castillo, 2012). Designing a program to assist pregnant teens in prenatal care, completing high school and being strong self sufficient parents will decrease the negative affect it can have on the economy as well as the offspring of these teens. This program will be giving teens a brighter future for themselves, their children and the economy.

PREGNANT TEEN CASE MANAGEMENT References About teen pregnancy. (2011). Retrieved from http//www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm

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Ackerman, L. (1997, Sept-Oct). Health problems of refugees [Journal]. PubMed.gov, 10(5), 337348. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9297659 Alford, S. (2009). Best practices for youth friendly clinical services. Retrieved from http://www.advocatesforyouth.org/component/content/article/106-publications/1347-best-practices-for-youth-friendly-clinical-services Allender, J. A., Rector, C., & Warner, K. D. (2010). Community Health Nursing (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. CHIP Pennsylvanias Childrens Health Insurance Program. (n.d.). http://wwww.chipcoverspakids.com Castillo, M. (2012). U.S. teen pregnancy rates at an all-time low across all ethnicities. Retrieved from http://www.cbsnews.com/8301-504763_162-57411981-10391704/u.s.-teenpregnancy-rates-at-an-all-time-low-acros-all-etnicities/ Cornett, C. (2010). 15 Tips to help designers gain stakeholder buy-in. Retrieved from http://www.inspireux.com/2010/09/27/15-tips-to-help-designers-gain-stakeholder-buyin/ County Health Rankings. (2011). http://www.countyhelathrankings.org/pennsylvania/delaware Crozer Keystone Health System. (2012). http://www.crozerkeystone.org Delaware County Intermediate Unit. (n.d). http://www.dciu.org Delaware County Teen Pregnancy Prevention Coalition. (n.d). http://www.delcoteenpregnancyprevention.org/About-Us/html

PREGNANT TEEN CASE MANAGEMENT Delaware County resource guide. (n.d.). Retrieved from http://www.delcosuicideprevention.org/Resources/resource_guide.html Finkelman, A. W. (2011). Case management for nurses. Saddle River, NJ: Pearson Education. Garofalo, R., & Forcier, M. (2011). Adolescent sexuality. Retrieved from http://www.uptodate.com/contents/adolescent-sexuality?view=print Hardy, D. (2001, March 08). For Pregnant Teens, Programs Offer A Lifeline Two That Teach

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Parenting and Keep Students In School Cited Success. Organizers Want to Expand Their Effort. The Inquirer. Retrieved from http://www.articles.philly.com/2001-0308/news/25326673_1_parenting-program-teen-parents-young-parents Implementing healthy people 2020. (n.d.). Retrieved from http://www.healthypeople.gov/2020/implementing/default.aspx In-home case management cuts cost of care [Journal]. (2012). Case Management Advisor, 23(3), 27-29. Retrieved from http://search.ebscohost.com Introduction to program evaluation for public health programs. (2006). Retrieved from http:/www.cdc.gov/getsmart/program-planner/Introduction.html Managing a high-risk pregnancy. (n.d.). Retrieved from http://www.webmd.com/baby/guide/managing-a-risk-pregnancy Maternal Mortality. (2006). Retrieved from http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONA NDPOPULATION/EXTPHAAG/0,,contentMDK:20944136~menuPK:2656916~pagePK :64229817~piPK:64229743~theSitePK:672263,00.html Maternal health. (2011). Retrieved from http://www.who.int/topics/maternal_health/en/

PREGNANT TEEN CASE MANAGEMENT Metro Council for Teen Potential. (2009). Breaking the cycle: A strength-based practice guide for case managers who work with teen parents. Retrieved from http://www.metrocouncil.us/pdf/breaking_the_cycle.pdf

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National Association of County & City Health Officials. (2009). Meeting the needs of pregnant and parenting teens: Local health department programs and services. Retrieved from www.naccho.org: http://www.dhs.state.mn.us/main/groups/agencywide/documents/pub/dhs16_148996.pdf Nutrition during pregnancy. (2011). Retrieved from http://www.acog.org/pulications/patient_education/bp001.cfm Planned Parenthood. (n.d). http://www.planedparenthood.org/healthcenter/centerDetails.asp?f=2337&a=91460&v=detao;s Pregnancy and Weight Gain. (2010). Retrieved from http://www.webmd.com/baby/guice/healthy-weight-gain Ready for pregnancy. (2011). Retrieved from http://cdc.gov/Features/PregnancyHealthTips/ Safe motherhood and maternal health. (2011). Retrieved from http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONA NDPOPULATION/EXTPRH/0,,contentMDK:20200213~menuPK:548457~pagePK:148 956~piPK:216618~theSitePK:376855,00.html Teen Pregnancy: Medical Risks and Realities. (2010). Retrieved from http://www.webmd.com/baby/teen-pregnancy-medical-risks-and realities Teen Pregnancy: The Importance of Prevention. (2011). Retrieved from http://www.cdc.gov/features/vitalsigns/TeenPregnancy/

PREGNANT TEEN CASE MANAGEMENT Teenage Pregnancy. (2011). Retrieved from http://www.marchofdimes.com/medicalresources_teenprenancy.html The National Campaign to Prevent Teen and Unplanned Pregnancy. (2012). http://www.thnationalcampaign.org/about-us/what-we-do.aspx The Robert Wood Johnson Foundation. (2009). A practical guide for engaging stakeholders in developing evaluation questions. Retrieved from http://www.rwjf.org/pr/product.jsp?id=49951 The Working Group for a Delaware County Health Department. (2011). Retrieved from http://www.delcohealth.org/ Upper Darby School District. (2011). http://www.upperdarbysd.org/districtinformation/community-profile Van Dijik, J. W., Anderko, L., & Stetzer, F. (2011, Jan-Feb). The impact of prenatal care

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