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Policy Innovation Profile

Statewide Medical Home Program for Low-Income Pregnant Women Enhances Access to Comprehensive Prenatal Care and Case Management, Improves Outcomes


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Snapshot

Summary

A statewide, public–private partnership known as Community Care of North Carolina adapted its successful primary care medical home model for use with pregnant Medicaid beneficiaries. The partnership oversees a network of 14 regional networks that recruit and support participating providers. These providers agree to complete a risk assessment for each pregnant beneficiary, collaborate with a care manager assigned to high-risk pregnancies, adhere to certain process and performance standards, and designate a practice champion. Participating primary care practices receive per-member, per-month payments from Medicaid (in addition to standard fee-for-service payments). The partnership's central office supports the networks through analysis of claims, birth certificate, and care management data; technical assistance; and quality improvement support. The initiative has enhanced access to comprehensive care for pregnant Medicaid beneficiaries, including access to care coordination for those facing high-risk pregnancies. Preliminary data suggest it has also increased provider adherence to evidence-based care standards and has begun to have a positive impact on the incidence of low birth weight and rate of primary Cesarean sections.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on the number of practices signing up for the program, the proportion of all pregnant Medicaid beneficiaries screened for risk factors, and the proportion of high-risk women connected to a care manager; additional evidence includes pre- and post-implementation comparisons of the use of progesterone in high-risk women, incidence of low–birth weight and very low–birth weight births, and rate of primary Cesarean sections.
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Developing Organizations

Community Care of North Carolina
Community Care of North Carolina developed the initiative, but it is a three-way partnership with the North Carolina Division of Medical Assistance (Medicaid) and the North Carolina Division of Public Health.end do

Date First Implemented

2011
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Patient Population

Gender > Female; Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Womenend pp

Problem Addressed

Preterm births—defined as birth before 37 weeks gestation—are common and often lead to serious health problems, including death and long-term neurological disabilities. Certain preventable or treatable health behaviors and conditions increase the likelihood of preterm birth, particularly among low-income women. Comprehensive, coordinated care (such as that offered in a patient-centered medical home) can help to address these risk factors, yet most low-income pregnant women do not have access to this type of care.
  • Many preterm births, leading to significant health problems: More than 1 in 10 babies in the United States are born before 37 weeks gestation, with rates being highest in the southeastern United States and among low-income women, including those eligible for Medicaid.1,2 Preterm births are the leading cause of infant mortality in this country, and preterm babies who do survive often have poor health and low quality of life, and typically generate high health care expenses. Preterm babies, for example, face an increased risk of cerebral palsy, hearing loss, respiratory problems, and intellectual/neurological disabilities.1
  • Many common risk factors, particularly among low-income women: Certain preventable or treatable health behaviors and conditions increase the risk of a preterm birth, including smoking, substance abuse, inadequate prenatal care, certain chronic conditions, and having had a prior preterm birth. These risk factors tend to be more common among low-income women, including those on Medicaid.2
  • Unrealized potential of comprehensive, coordinated care management: Comprehensive, coordinated care management can help identify and address these risk factors by addressing housing, nutrition, and tobacco/substance abuse issues; facilitating access to the full range of needed medical care; and encouraging adherence to evidence-based standards of care. Patient-centered medical homes routinely offer this type of care, but low-income, high-risk pregnant women often do not have access. For example, before implementation of this program in North Carolina, the existing fee-for-service (FFS) maternity case management program reached only 32 percent of Medicaid-eligible pregnant women, and it did not prioritize at-risk women for more intensive services (instead serving women on a first-come, first-served basis).

What They Did

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Description of the Innovative Activity

Community Care of North Carolina adapted its successful primary care medical home model for use with pregnant Medicaid beneficiaries. This statewide partnership oversees a network of 14 regional networks that recruit and support participating providers. These providers agree to complete a risk assessment for each pregnant beneficiary, collaborate with a care manager assigned to high-risk pregnancies, adhere to certain process and performance standards, and designate a practice champion. Participating primary care practices receive per-member, per-month payments from Medicaid (in addition to standard FFS payments). The additional resources help primary care practices provide more robust care management and care coordination with other providers. The partnership's central office supports the networks through data collection and analysis and assistance with technical issues and quality improvement. Key elements of this patient-centered medical home model for pregnant women are outlined below:
  • Community networks that recruit and support providers: Community Care of North Carolina oversees 14 regional, self-governing community networks that recruit, contract with, and train providers for this program. These networks came into existence as part of a primary care medical home model that preceded this program. (See Planning and Development Process section for more details.)
  • Provider participation requirements: Providers who contract with 1 of the 14 networks agree to adhere to various policies, including performing risk assessments for all pregnant beneficiaries, coordinating with care managers assigned to high-risk women, adhering to various process and performance standards designed to improve outcomes, and designating a practice champion. More details on these policies are provided below:
    • Mandatory risk assessment: Participating providers agree to perform a risk assessment for all pregnant Medicaid beneficiaries at the first prenatal visit. The assessment evaluates 27 potential risks for preterm birth or other adverse pregnancy outcomes. The presence of any of 10 "priority" risk factors automatically makes the candidate a high priority for assignment to a case manager (see below). The 10 risk factors include current or recent tobacco or substance use, unstable living situation or domestic violence, presence of chronic disease, previous preterm birth or low–birth weight baby, current fetal complication, delayed prenatal care; two or more missed appointments, and recent hospitalization or emergency department use.
    • Referral to and coordination with care managers for high-risk cases: Participating providers must refer any high-risk patient to care management within 1 week of the screening, and agree to integrate the care manager (specially trained nurses or social workers housed in public health agencies) into the prenatal care team. Depending on the needs of the patient, the care managers may perform any of the following tasks designed to ensure care is patient centered, coordinated, and comprehensive:
      • Care plans: Care managers develop and document patient-centered care plans based on patient needs.
      • Referrals: Care managers provide referrals to childbirth education, dental care, behavioral health, or other needed services covered by Medicaid. They also provide referrals to needed community resources, including substance abuse treatment programs, food pantries, and housing or transportation assistance.
      • Transition after pregnancy: Care managers assist with the transition from the pregnancy medical home to a primary care medical home for patients who remain eligible for Medicaid beyond the post partum period.
    • Adherence to process and performance standards: Participating providers agree to adhere to various process and performance standards designed to enhance the accessibility, safety, and quality of care. These standards include the following:
      • Having a provider (physician, physician assistant, nurse practitioner, midwife, or enhanced-role nurse) available to see pregnant patients at least 30 hours a week.
      • Providing 24-hour telephone consultation/triage for all pregnant patients, and having a clear policy on where and how patients should seek medical assistance outside of office hours.
      • Providing all pregnant Medicaid patients with information about prenatal self- management and about the various benefits available to pregnant women and women with infants, including the Women, Infants, and Children (WIC) program, the Medicaid for Pregnant Women program (which raises the income cutoff for pregnant women, thus giving eligibility to women who may not qualify for Medicaid in the absence of a pregnancy), and the Family Planning Waiver (which increases the number of reproductive age women and men who may receive Medicaid-funded family planning services).
      • Administering progesterone (also known as 17p) to eligible women with a history of preterm birth. (Medicaid covers this medication provided it is properly documented in the record.)
      • Avoiding elective deliveries before 39 weeks gestation.
      • Maintaining a primary Cesarean section rate of 16 percent or lower among low-risk first-birth women (also known as nulliparous term singleton vertex fetus).
      • Conducting post partum visits that include depression screening, a discussion of reproductive life planning, and connecting the patient to a primary care medical home.
    • Practice champion: Each participating practice agrees to have an in-house champion who promotes the program and its principles.
  • Incentives for providers: Participating providers can earn incentives (paid by the State Medicaid agency) by signing a contract with their local Community Care of North Carolina network and agreeing to meet the program's performance expectations. Incentives include a $50 payment for performing the initial risk assessment and a $150 payment for completing a post partum visit. Participating providers also receive reimbursement for vaginal deliveries that equal that provided for a Cesarean section. The State Medicaid division also removed an existing barrier to providing pregnancy-related ultrasounds, as it no longer requires preauthorization for the procedure when the ordering provider participates in the program.
    • Central office oversight and support: Community Care of North Carolina's central office provides various forms of oversight and support to the 14 networks and to participating providers, as outlined below:
      • Electronic documentation tools: Care managers use an electronic documentation system (developed to support the preexisting primary care medical home model and modified for pregnant patients) to record all case management activities.
      • Standardized care pathways: In consultation with academic medical centers and physician champions statewide, a central team of physicians, nurse coordinators, and consultants from the Division of Public Health develops care pathways that establish evidence-based standards of care for clinicians and expectations for care managers throughout the state. Pathways cover various pregnancy-related conditions, including hypertensive disorders and tobacco cessation. Pathways are circulated among providers and care managers with specific, local followup activities combined with statewide webinars to ensure dissemination and uptake.
      • Data collection and analysis to stimulate improvement: Community Care of North Carolina's informatics staff integrates claims data and information from birth certificates and hospital admissions and data from the pregnancy care management electronic documentation system to evaluate adherence to agreed-to standards and pregnancy outcomes, with the goal of identifying opportunities for improvement.
      • Technical and quality improvement support: The central office offers technical and quality improvement support to the 14 networks, including providing the data infrastructure, overseeing quality improvement efforts, training and supporting care managers, and convening regular meetings of network representatives. Each of the 14 networks has a Pregnancy Medical Home team consisting of at least 1 nurse coordinator and 1 physician champion. With support from the central office, team members meet regularly by telephone and in person to discuss ways to promote program goals and deal with challenges they face along the way. Topics covered during the first year of the program include access to specialty care (particularly behavioral health services), opiate dependence during pregnancy, and improving access to long-acting contraceptives and oral health care.

    Context of the Innovation

    Community Care of North Carolina is a public-partnership that brings together community-based providers with state-led efforts to better serve the health care needs of Medicaid-eligible patients. It began in the late 1990s when multiple organizations—including the Office of Rural Health and Community Care, the Division of Medical Assistance, the North Carolina Foundation for Advanced Health Programs, and the Kate B. Reynolds Health Care Trust (a philanthropic organization)—came together to create a medical home model to increase the quality and efficiency of primary care for Medicaid beneficiaries throughout North Carolina. That initiative includes 14 regional networks that contract and work with providers to provide team-based, comprehensive primary care to Medicaid beneficiaries. (The primary care medical home is featured in a separate profile, available at http://innovations.ahrq.gov/content.aspx?id=3844).

    As detailed in the Planning and Development Process section below, consideration was given to creating a medical home model for pregnant women during discussions about expanding the primary care medical home, and this discussion later resurfaced after that model proved successful. Work to adapt the primary care model to pregnancy began in early 2010. The pregnancy medical home model launched as a three-way partnership among Community Care of North Carolina, Division of Medical Assistance and Division of Public Health in 2011.

    The patient-centered medical home model aims to meet a patient's full range of health care needs through coordinated, team-based care and a systems-based approach to improving quality and safety. The Affordable Care Act of 2010 supports the use of this model to increase the quality, efficiency, and accessibility of health care and authorizes demonstration projects to prove the models effectiveness.

    Did It Work?

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    Results

    The Pregnancy Medical Home initiative has improved access to comprehensive care for pregnant Medicaid beneficiaries, including access to case manager–led care coordination for those facing high-risk pregnancies. Preliminary data suggest it has also increased provider adherence to evidence-based care standards and has begun to have a positive impact on the incidence of low–birth weight babies and rate of primary Cesarean sections.
    • Enhanced access to comprehensive pregnancy care: More than 350 practices that collectively have more than 1,500 obstetricians, family physicians, midwives, nurse practitioners, and physician assistants have signed on to the program and committed to establishing patient-centered pregnancy medical homes for pregnant Medicaid beneficiaries. These providers account for 85 percent of all practices that provide prenatal care to Medicaid patients in North Carolina. Since joining the program, some of these practices now accept more Medicaid patients than in the past.
    • Enhanced access to care management for high-risk women: Between January and June 2012, more than 75 percent of pregnant Medicaid patients (a total of 20,288 women) were screened for risk factors, with more than two-thirds of those screened having at least 1 risk factor identified that made them eligible for referral to a care manager. More than 80 percent of these women had contact with their care manager during the course of their prenatal care. The previous FFS care management program (which cost roughly the same amount of money) reached 32 percent of all pregnant women receiving Medicaid but didn't necessarily focus care management on those most at risk.
    • Better adherence to evidence-based standards: Preliminary analysis of claims data suggests that use and documentation of progesterone in high-risk women has increased, thus reducing the risk of preterm labor and decreasing out-of-pocket expenses for women who previously received the treatment without reimbursement.
    • Early signs of improved outcomes: Although the program has been in place only since 2011, preliminary analysis shows positive trends that should lead to better outcomes and lower health care costs, especially in an infant's first year of life. These trends include the following:
      • Fewer low–birth weight babies: Rates of low birth weight (less than 5.5 pounds at birth) among women with prenatal Medicaid coverage fell from 11.12 to 10.8 percent of births between 2011 and 2012, a nearly 3-percent decline. The incidence of very low–birth weight deliveries (less than 3.3 pounds at birth) fell 6.4 percent over the same time period.
      • Slightly fewer primary Cesarean sections: The proportion of pregnant Medicaid recipients having a primary Cesarean section fell slightly between 2011 and 2012, from 16.16 percent to 16.07 percent.

    Evidence Rating (What is this?)

    Moderate: The evidence consists of post-implementation data on the number of practices signing up for the program, the proportion of all pregnant Medicaid beneficiaries screened for risk factors, and the proportion of high-risk women connected to a care manager; additional evidence includes pre- and post-implementation comparisons of the use of progesterone in high-risk women, incidence of low–birth weight and very low–birth weight births, and rate of primary Cesarean sections.

    How They Did It

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    Planning and Development Process

    Key steps included the following:
    • Reviving earlier idea: After the successful implementation of the primary care medical home model, developers discussed in 2008 adapting and expanding the model for different situations, including management of the Medicaid high-risk obstetrics population. However, without resources to adapt the model for high-risk pregnancy, the plan was put on hold. When a former obstetrician came on board as director of the Division of Medical Assistance (which administers the Medicaid program in North Carolina) in 2009, the partners revived and pushed forward the idea of the pregnancy medical home.
    • Developing concept paper: Community Care of North Carolina worked with staff at the University of North Carolina School of Medicine and Center for Maternal and Infant Health to develop a white paper that explores the issues, benefits, and goals of applying the medical home model to pregnancy.
    • Building on existing foundation: As noted, Community Care of North Carolina already had 14 provider networks in place throughout the state that recruit and contract with local providers to serve Medicaid patients in a medical home, including Federally Qualified Health Centers, local health departments, and private practitioners. Program leaders decided to leverage these existing networks when creating the pregnancy medical home initiative.
    • Deciding to use existing maternity care coordinators: As noted, North Carolina had an existing maternity case management program that operated on a FFS basis, serving pregnant women on a first-come, first-serve basis (rather than prioritizing based on risk). Instead of disbanding this program and directly hiring case managers (the approach used in the primary care medical home model), Community Care of North Carolina leaders agreed to work with the State Division of Public Health to retrain existing case managers (mostly housed in regional public health departments) to work in the new pregnancy medical home model.
    • Developing risk assessment tool: Community Care of North Carolina brought together a multidisciplinary committee of patients, obstetricians, midwives, substance abuse counselors, mental health professionals, social workers, care managers, and public health officials who worked together to identify the 10 priority risk factors that would automatically trigger a referral to care management. With one exception, they chose these factors based on evidence in the literature. The exception was unstable housing. Although the literature does not show a direct link between homelessness and preterm births, committee members included this risk factor because they felt that secure housing is critically important to the quality of life for both mother and infant.
    • Adapting electronic documentation system: Community Care of North Carolina had previously developed an electronic documentation system to support the primary care medical home model. The system serves as an electronic patient record to capture case management activities. This system was modified to include pregnancy-related components for use by the care managers.
    • Retraining maternity care coordinators: Community Care of North Carolina and the State Division of Public Health partnered to provide training to the existing maternity case managers working in the FFS program, teaching them about the medical home model, its population-based approach to prenatal care, and the electronic documentation system. Much of the training focused on documentation, since the FFS program generally used a paper-based approach to documentation, as well as the key focus of collaboration with the prenatal care provider.
    • Hiring nurse coordinators and physician champions: Each of the 14 networks hired at least 1 nurse coordinator and 1 physician champion to serve as the network's obstetrics team that recruits and supports providers, pregnancy case management organizations, and other community partners in reaching program goals. As noted earlier, these teams also have regular statewide meetings to deal with ongoing challenges and program development.

    Resources Used and Skills Needed

    • Staffing: Community Care of North Carolina's central office has one full-time nurse program coordinator and one part-time physician champion who provide oversight and guidance for the program. The team is supported by a dedicated data analyst and an analytics manager and works collaboratively with the central office's behavioral health coordinator, assistant director of pharmacy, lead psychiatrist, lead pediatrician, and quality improvement team. In addition, each local network contracts with local public health organizations to provide 320 pregnancy care managers statewide to work with providers in their region. The Division of Public Health employs a program manager and a consultant team of four people who support the care managers with training and technical assistance. In addition to these state-level positions, each of the 14 networks has at least 1 obstetrics nurse coordinator (based on population) and a part-time physician champion (who dedicates between 1 and 8 hours a week to the program). Each network also has someone who provides training and technical support related to the electronic documentation system.
    • Costs: Community Care of North Carolina has an annual budget of $1.2 million for the pregnancy medical home model, which covers the direct staff and informatics and other support at the central office and the 14 networks. In addition, the care management component of the program costs roughly $18.5 million a year.
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    Funding Sources

    North Carolina Division of Medical Assistance
    The State Medicaid program covers the costs of the care management component of the program as well as the central office and network-level infrastructure through population-based per-member, per-month payments.end fs

    Tools and Other Resources

    NC Department of Health and Human Services/North Carolina Public Health, Women's Health Branch. Pregnancy care management program manual. Available at: http://whb.ncpublichealth.com/provpart/pubmanbro.htm. (Online manual includes fact sheets, risk screening forms, and other materials associated with the Pregnancy Medical Home model.)

    Adoption Considerations

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    Getting Started with This Innovation

    • Build on existing foundation: Rather than starting from scratch, program leaders decided to build on the existing Medicaid medical home program for primary care and the maternity case management program, adapting each of them to develop a population-based program for pregnant women.
    • Think through application of medical home principles to pregnancy: Although the principles of a primary care medical home—comprehensive, team-based care designed to improve health outcomes and efficiency for a population—are the same for pregnancy, they may play out differently in practice. For example, the relationship between patient and provider may not extend beyond the pregnancy. In addition, the Medicaid program raises the income level for eligibility during pregnancy, meaning that many women only qualify for coverage while pregnant.
    • Include key stakeholders in program design: Medical management of low-income women with high-risk pregnancies requires a team approach that can easily adapt to their different, varying needs. Some women may require relatively routine medical care whereas others need intensive interventions and support to address existing mental health issues, substance abuse problems, chronic conditions, a history of preterm births, or housing issues. For example, women who have a recent history of substance abuse and a prior history of preterm birth may require both close medical supervision and intensive social services. Designing a flexible program that can meet these varying needs requires careful planning, with input from a variety of stakeholders.
    • Identify and articulate clear, measurable goals: Program leaders decided to focus this program specifically on reducing the incidence of low–birth weight babies and use of primary Cesarean sections because they represent clear, easily measured public health problems that undermine quality and increase health care costs.
    • Enlist champions at all levels: Professionals who believe in the program and its benefits can be invaluable to efforts to recruit new providers and deal with implementation challenges. As noted, the North Carolina program includes a state-level physician champion, along with champions at the network and practice levels.
    • Give local practices flexibility in setting up care team: Although providers and care managers agree to work together on the prenatal care team, the structure for this collaboration varies based on the needs of each practice and its patient population.

    Sustaining This Innovation

    • Provide ongoing training: Although all pregnancy care managers received initial training on the electronic documentation system, the need for periodic training on documentation and strategies for managing a high-risk population continues beyond program launch.
    • Leverage central office to support program: As noted, the central office of Community Care of North Carolina provides a variety of ongoing assistance in support of the program, including data collection and analysis, and technical and quality improvement support (e.g., development of practice-level data and statewide performance metrics).
    • Consult network champions and nurse coordinators regularly: As noted, physician champions and nurse coordinators meet regularly by telephone and in person to discuss issues and challenges they are facing.

    Spreading This Innovation

    Leaders of Community Care of North Carolina have consulted with officials in several other states who are interested in setting up a similar program.

    More Information

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    Contact the Innovator

    Kate Berrien, RN, BSN, MS
    Pregnancy Home Project Coordinator
    Community Care of North Carolina
    2300 Rexwoods Drive, Suite 100
    Raleigh, NC 27607
    (919) 745-2384
    E-mail: kberrien@n3cn.org

    Innovator Disclosures

    According to the innovator, Community Care of North Carolina receives funds from the North Carolina chapter of the American College of Obstetricians and Gynecologists and the March of Dimes.

    References/Related Articles

    Agency for Healthcare Research and Quality. Closing the Quality Gap: Revisiting the State of the Science. Summary Report, publication no. 12(13)-E017. Available at: http://effectivehealthcare.ahrq.gov/ehc/products/496/1375
    /ClosingtheQualityGap_SummaryReport_20130109.pdf
    (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

    A description of the original primary care medical home model is available at: http://innovations.ahrq.gov/content.aspx?id=3844.

    Footnotes

    1 Centers for Disease Control and Prevention. Preterm birth fact sheet, 2012. Available at: http://www.cdc.gov/reproductivehealth/maternalinfanthealth/PretermBirth.htm.
    2 Anum EA, Retchin SM, Strauss JF. Medicaid and preterm birth and low birth weight: the last two decades. J Womens Health. 2010;19(3):443-51. [PubMed]
    Comment on this Innovation

    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: January 30, 2013.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: April 09, 2014.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.