Module 15: The Pregnancy Medical Home
Background: Medicaid coverage of perinatal care and North Carolina statistics
Nationally, Medicaid pays for more than 40 percent of all births, and in North Carolina just over 50 percent of the 126,785 deliveries in 2009 were covered by Medicaid1. North Carolina consistently ranks in the top quartile of states in terms of the prevalence of low birth weight, preterm birth and infant mortality. In spite of consistent improvement over the past 20 years, North Carolina’s rate of infant mortality in 2009 was 7.9 infant deaths per 1,000 live births2, compared to 6.42 deaths per 1,000 live births nationally3. The disparity in infant mortality between Caucasian infants and minority infants also has increased; in fact, the infant mortality rate for minorities is now more than double that of Caucasian infants. In North Carolina, the rate of preterm birth began to decline modestly in 2005 after two decades of steady increases, but it remains higher than the national average4. The rate of low birth weight also continues to exceed the national average5, as well as the Healthy People 2010 goal of no more than five percent of all births6. Among all North Carolina births, the rate of low birth weight was 9.1 percent in 2009; in the Medicaid population, the rate of low birth weight was 10.3 percent7.
Of the 64,439 births in North Carolina covered by Medicaid in 2009, approximately 18.5 percent, or 11,990, were “emergency Medicaid” deliveries. This means Medicaid paid only for the delivery, not prenatal care, because these mothers were not eligible for Medicaid coverage during their pregnancy. The remaining 52,449 mothers had Medicaid coverage for both prenatal care and delivery. Approximately two-thirds of these women were covered under the category Medicaid for Pregnant Women, suggesting they are not eligible for ongoing Medicaid coverage outside of pregnancy. These women, therefore, are unlikely to be connected to a primary care medical home or have a consistent source of health care services when they are not pregnant.
Community Care of N.C. and the Development of the Pregnancy Home
In an effort to improve birth outcomes and control costs associated with high rates of low birth weight and preterm birth, Community Care of North Carolina and the N.C. Division of Medical Assistance (DMA) jointly developed a Pregnancy Home model, based on Community Care’s successful primary care medical home program. In addition, the Division of Public Health (DPH) was engaged as a third partner to integrate care management for pregnant Medicaid recipients, which is provided through the public health infrastructure. The goals of developing a pregnancy home model for the delivery of maternity care to Medicaid patients include:
- Provision of comprehensive, coordinated, high-quality maternity care to Medicaid recipients.
- Improved birth outcomes among the Medicaid population.
- Improved stewardship of public funds for perinatal health.
- Quality improvement in perinatal health care services.
Because maternity patients may have a time-limited relationship with their prenatal care provider (often as a result of loss of Medicaid coverage beyond the maternity episode), some features differ significantly from the primary care medical home structure. Nonetheless, the following principles have been applied to the Pregnancy Home program:
- Engagement of obstetric care providers in Community Care networks.
- Standardized performance measures for all Pregnancy Medical Home practices.
- Population management approach to the pregnant Medicaid population.
- Stratification of the pregnant population to focus resources on “high-cost, high-need” patients.
- Care management of those patients identified as being at risk of poor birth outcome.
Engagement of obstetric care providers: While obstetric and nurse-midwifery practices have always been eligible to join Community Care as primary care medical homes, in many parts of the state these providers were not engaged in their local networks. Informal feedback suggests the performance standards in the primary care medical home model did not seem as relevant to some obstetric care providers, who nevertheless may be the only source of primary care for women of childbearing age. In the Pregnancy Home model, obstetric care providers are engaged in a Community Care initiative with a specific focus on maternity care.
This program supports an “OB team” at each Community Care network, consisting of an OB physician champion and an OB nurse coordinator to recruit, educate and support Pregnancy Medical Home practices. Each OB champion is a clinician who is a locally recognized opinion leader and trusted resource for maternity care providers in that community. OB nurse coordinators tend to have both clinical experience in high-risk obstetrics as well as a background in community and/or public health.
Performance measures: Developed collaboratively by DMA, DPH and Community Care, the program’s targeted outcomes address the dual priorities of improving birth outcomes and reducing costs. In addition to global measures applied at the state and network level, specific performance standards for Pregnancy Medical Home practices ensure that pregnant Medicaid patients receive certain standards of care regardless of where they choose to seek maternity care.
Broad global performance measures for this program address the dual priorities of this model: improving birth outcomes and lowering costs. Specific targets for Pregnancy Medical Home practices and for the Pregnancy Care Management program reflect expectations for each of these components and are described in more detail under the “Pregnancy Medical Home Expectations” and “Pregnancy Care Management” sections below.
Global performance measures include:
- Reduction in the rate of low birth weight among pregnant Medicaid patients.
- Maintaining the primary cesarean section rate at or below a threshold level (currently 20 percent).
- Maintaining the primary cesarean section rate among patients at term with a singleton, vertex fetus at or below a threshold level (currently 16 percent).
Population management approach: The Pregnancy Home initiative represents the first application of a population management approach to the pregnant Medicaid population in North Carolina. Networks in partnership with local health departments will participate in efforts to facilitate early entry and improved access to prenatal care for Medicaid recipients and develop community partnerships to promote the health of this population both during pregnancy and throughout the childbearing years. Standardized risk screening of pregnant Medicaid patients in Pregnancy Medical homes allows for identification of this population in real time; and use of data from Medicaid claims, birth certificates and other sources allows for retrospective data analysis of this population.
Population stratification: Using a standardized risk-screening process, patients with “priority” risk factors can be identified so that care managers can focus on developing care plans to address those areas of concern. The priority risk factors are those with a demonstrated link to preterm birth, the key driver of the rate of low birth weight. (See below for more information on risk screening.)
Care management: Each Pregnancy Medical Home has an assigned care manager who provides support following the Community Care primary care model (See Module 11 for more information). Pregnancy care managers focus on developing individualized care plans for those patients with risk factors for poor birth outcomes. Service intensity varies according to the needs of each patient. (For more details, see “Pregnancy Care Management” below.)
Pregnancy Medical Home Practices
Any practice or clinic providing prenatal care to Medicaid patients is eligible to contract with the local Community Care network and serve as a Pregnancy Medical Home.
Pregnancy Medical Home practices have specific expectations:
- Elimination of elective deliveries (induction of labor and cesarean section) before 39 weeks of gestation.
- Offering and providing 17p to eligible patients based on American Congress of Obstetricians and Gynecologists (ACOG) guidelines to prevent recurrent preterm birth.
- Maintaining a primary cesarean section rate at or below 20 percent.
- Performing standardized risk screening on all new prenatal patients.
- Refer high-risk pregnant women to the practice’s assigned care management for follow-up.
The first two items reflect the focus on preterm birth prevention. Some infants delivered electively at 37 or 38 weeks of estimated gestation may actually be fewer than 37 weeks old and will likely experience the complications associated with late preterm birth. 17p (17alpha Hydroxyprogesterone), delivered by weekly intramuscular injection beginning at 16-21 weeks of gestation through the 36th completed week of pregnancy, has been demonstrated to reduce a woman’s risk of recurrent preterm birth by 33 percent. A reduction in the primary c-section rate (the rate of women having their first c-section) not only avoids cost and risks in the current pregnancy, but may also reduce complications (and their associated costs and long-term health issues) in future pregnancies, given that most women will have c-sections in all deliveries after having had one cesarean delivery.
Patients are not formally linked to a Pregnancy Medical Home practice, so there is no “enrolled” population. All Medicaid patients at a Pregnancy Medical Home practice are considered to be Pregnancy Medical Home patients. Instead of receiving a “per member per month” payment, Pregnancy Medical Home practices receive specific incentive payments and enhanced rates. These financial mechanisms are used to engage obstetric providers and reward them for their commitment to high standards of care and quality improvement efforts.
Incentives to engage Pregnancy Medical Home practices and drive quality improvement include:
- $50 incentive payment for completing standardized risk screening.
- $150 incentive payment for performing a postpartum visit.
- The postpartum visit must, at a minimum, include a depression screen using a validated instrument, address the patient’s reproductive life plan, and involve referral for ongoing care beyond the maternity period.
- Rate increase of 13.2 percent for all vaginal deliveries, such that the global fee for vaginal delivery is equal to the global fee for cesarean section (the increased rate applies to antepartum package services, delivery-only fees and postpartum package services).
- Bypass of prior authorization requirement for OB ultrasound.
Pregnancy Medical Home practices are expected to provide comprehensive, coordinated maternity care, working in partnership with pregnancy care managers. Because pregnant patients may transition across care settings (e.g., to high-risk clinics, antepartum hospitalization or to obstetrical services for intrapartum care if their prenatal care provider does not perform deliveries), a key focus is on ensuring a seamless handoff for the patient from one care provider to the next (and back to the patient’s primary maternity care provider).
Risk Screening of the Pregnant Medicaid Population
While it is not possible to predict which pregnancies will result in poor birth outcomes such as preterm birth or low birth weight, certain risk factors are associated with a greater likelihood of poor outcome. A Community Care multidisciplinary workgroup generated a list of risk factors representing both medical complications of pregnancy and psychosocial issues that can impact pregnancy outcome. From this list, a group of ten priority risk factors were identified.
Priority risk factors include:
- History of spontaneous preterm birth.
- History of low birth weight.
- Chronic disease (including mental illness) that might complicate the pregnancy.
- Current/recent use of alcohol or drugs.
- Multifetal gestation.
- Fetal complications (such as fetal anomaly, chromosomal abnormality, oligohydramnios).
- Current tobacco use (or discontinuation of tobacco use during the current pregnancy).
- Unsafe living environment (including domestic violence or other abuse, homelessness, inadequate housing, etc.).
- Late entry to prenatal care and/or missing two or more prenatal appointments.
- Hospitalization during the antepartum period.
The selection of these risk factors was based on available evidence supporting their association with preterm birth and low birth weight as well as the desire to bring a holistic approach to defining “high-risk” pregnancy. While there are other risk factors associated with poor birth outcomes or other pregnancy complications, the primary focus is on preventing preterm birth, the leading cause of infant mortality, low birth weight and need for neonatal intensive care. Some of the utilization factors (e.g., late entry to prenatal care, missed prenatal appointments, hospitalization) will capture patients with a broad range of issues that might affect the pregnancy.
The expectation is that roughly half of the pregnant Medicaid population will have at least one priority risk factor. Over time, the program focus may shift based on emerging evidence and our own data analysis, which will be greatly improved as a result of having standardized risk screening information.
Timing of risk screening: All Pregnancy Medical Home practices are expected to conduct risk screening at the first prenatal visit. Results of risk screening are provided to the pregnancy care managers, who will conduct a thorough assessment with those patients identified as having priority risk factors. In addition to the presence of any of the 10 priority risk factors, the prenatal care provider can request care management follow-up for any patient based on his or her clinical judgment that the patient would benefit from care management intervention. Patients should be rescreened by the 28th week of gestation to identify any risk factors that have emerged since the initial assessment.
Risk screening form: Pregnancy Medical Home practices use the Community Care Initial Risk Screening Form to screen new OB patients. This form includes checkboxes for the clinician and a series of questions for the patient that can be self-administered. Where available, validated instruments are included to screen for specific risk factors, such as domestic violence, intention of pregnancy and smoking. A standardized follow-up risk screening form is also available.
Pregnancy Care Management
Each Pregnancy Medical Home practice has an assigned pregnancy care manager who will receive the risk screening forms and follow up directly with patients with priority risk factors and those referred for further assessment by the prenatal care provider. The pregnancy care manager will assess each patient across a range of dimensions, from access to health care and family support to substance abuse and financial issues. Once that evaluation is complete, he or she will develop an individualized care plan that responds to identified needs and agreed-upon goals.
Pregnancy care managers should be considered an integral part of the prenatal care team, extending the reach of the Pregnancy Medical Home into the community. By sharing information, the care manager can effectively support the clinical care plan ,and the clinician will have a more holistic understanding of the patient’s situation and factors that may affect her pregnancy.
Service intensity: As with primary care, the pregnancy care manager assigns the patient to a care status based on the level of need. Service intensity may fluctuate over the course of the pregnancy. All patients with a priority risk factor are kept at a minimum of “light” care management intensity through the postpartum period, to ensure they receive postpartum care, a key element in promoting health during the interconceptional period and in future pregnancies.
Unlike care management in the primary care setting, where “light” intensity indicates an average of an annual intervention, in pregnancy care management, patients on “light” status receive follow-up once per trimester. Because pregnancy care management occurs over a short timeframe with a limited window of opportunity to affect birth outcome, patients with priority risk factors should receive more frequent follow-up to identify quickly patients with care plan compliance issues and intervene accordingly. For patients with priority risk factors based on obstetric history who are stable in the current pregnancy, this may involve a quick consultation with the prenatal care provider to ensure the patient is receiving needed care. For a patient who has been referred to a community-based program, such as substance abuse treatment, per trimester follow-up allows the care manager to confirm she remains engaged with that program.
Staffing: Because risk factors leading to poor birth outcomes involve both clinical and psychosocial issues, the care management team should include a mix of disciplines, including nursing and social work. When social workers are providing pregnancy care management, they need access to skilled maternity nurses for consultation about patients with complex medical conditions. Similarly, nurse care managers need to utilize behavioral health resources when working with pregnant women whose primary risk factors relate to mental health, substance abuse and/or other psychosocial concerns.
Metrics applied to the pregnancy care management component include:
- Percent of pregnancy assessments completed on patients with one or more priority risk factors.
- Percent of risk screening forms entered into a Web-based care management documentation system (CMIS) within seven days.
- Percent of patients on 17p who receive all of the injections they are eligible to receive.
- Percent of patients referred for ongoing Medicaid eligibility, such as the Family Planning Waiver.
- Percent of patients who have a postpartum visit.
This program began in April 2011, and the Community Care networks have signed up 200 pregnancy homes as of June 1, 2011. Baseline data on the performance metrics will be collected to share with the pregnancy medical homes in the coming year.
North Carolina State Center for Health Statistics (NCSCHS). 2009 North Carolina Resident Live Births by Selected Risk Factors and Characteristics.
NCSCHS. North Carolina Vital Statistics Volume 1 2009.
National Vital Statistics System. Deaths: Preliminary Data for 2009; Volume 59, No. 4. March 16, 2011.
National Center for Health Statistics, 2008 preliminary, 2007, 2006 and 2005 final birth data. Retrieved May 30, 2011 from www.marchofdimes.com/peristats.
National Center for Health Statistics final natality data. Retrieved May 30, 2011 from www.marchofdimes.com/peristats.
U.S. Department of Health and Human Services, Healthy People 2010. Retrieved May 30, 2011 from www.healthypeople.gov.