Pregnancy Medical Home: Improving Maternal & Infant Outcomes in the Medicaid Population
New June 2021 PMH Data Brief
Click to download CCNC's latest data brief:
"The Maternal-Infant Impactability Score™ (MIIS) for Care Managers: A Demonstrated Approach for Reducing Low Birth Weight Through Pregnancy Care Management"
Community Care of North Carolina (CCNC) launched the Pregnancy Medical Home (PMH) program in 2011, to enhance access to comprehensive care for pregnant Medicaid beneficiaries and to improve birth outcomes. The PMH program promotes evidence-based, high-quality maternity care in more than 400 practices across the state. PMH practices represent 95% percent of prenatal care providers who serve the Medicaid population.
NASEM presentation by Dr. Kate Menard
CCNC gives presentation on advancing maternal health equity and reducing maternal mortality during a workshop hosted by the National Academies of Sciences, Engineering & Medicine (NASEM). The PDF presentation by M. Kathryn Menard, MD, MPH, distinguished professor of maternal-fetal medicine at UNC Chapel Hill and medical director of CCNC's Pregnancy Medical Home program, can be found alongside additional information on NASEM's website here.
PMH Care Pathways
Clinical guidance on management of conditions related to pregnancy
OB Guidance Documents
A collection of resources created by CCNC for PMH providers
Monthly PMH Newsletters
- September 2020
- October 2020
- November 2020
- December 2020
- January 2021
- February 2021
- March 2021
- June 2021
Majority OB Medicaid "MOM" Workgroup
- December 9, 2020 - Don't Leave Money on the Table: slide deck and recording
- January 14, 2021 - Sterilization Denials: slide deck
- February 11, 2021 - OB Ultrasound Denials: slide deck and recording
- March 11, 2021 - Managed Care High Level Overview: slide deck and recording
- April 11, 2021 - Beneficiary Enrollment/Newborn Eligibility/Updated Circumcision Policy: slide deck and recording
- May 13, 2021 - Managed Care & OB Specific Q&A: slide deck
- June 10, 2021 - Great Resources to Have on Hand: slide deck and recording
The PMH model includes six core components:
Statewide Provider Network
There are currently more than 450 practices and 2,500 individual providers, with PMH practices in 95 of 100 counties. This represents 95% of practices that serve pregnant women with Medicaid.
Standardized Risk Screening
Patients at risk of poor birth outcomes are identified through a standardized risk screen administered at the first prenatal visit. Nearly 80% of patients who receive care in a PMH are assessed using a standardized pregnancy risk screening tool. The screening tool captures medical, obstetric and psychosocial risk factors associated with preterm birth. In 2017, CCNC operationalized the Maternal-Infant Impactability Score™ (MIIS) stratification model. Every pregnant woman receives a score based on her own characteristics and risk factors, which reflects the relative ability of a care manager to reduce the risk of low birth weight when the woman receives intensive care management. Greater weight was given to those factors shown to improve with consistent and frequent care management.
Community-Based Care Management
Care Management for High Risk Pregnancies (CMHRP*) is a care coordination model for pregnant Medicaid patients at risk of preterm birth who were identified using the PMH risk screening form and other patient identification strategies. CMHRP services are provided by county health department nurses and social workers. These care managers partner with prenatal care providers; many are embedded in the prenatal care setting, enabling effective integration with the care team and face-to-face interaction with patients.
*CMHRP was previously called Pregnancy Care Management
Local Clinical Leadership
CCNC supports the PMH provider community through clinical leadership, provider education, technical assistance and by providing practice-level analytics. Statewide PMH clinical leadership teams (“OB teams”) support high quality care to the pregnant Medicaid population by disseminating statewide care pathways which establish best practices based on current evidence. OB teams also share meaningful data about key quality and performance metrics and support PMH practices to implement quality improvement strategies.
The PMH program promotes clinical best practices that reflect the most current evidence base in terms of strategies to prevent preterm birth. PMH Care Pathways, available on CCNC’s website, are used to standardize care, promote best practices, and set performance expectations across all PMH settings. PMH Care Pathways are developed by CCNC physician champions with input from local OB providers. Pathway topics focus on the management of pregnancy-related conditions, including hypertension, obesity, tobacco use, substance use, and multiple gestation, and specific components of care, such as induction of labor, progesterone treatment, postpartum care, and family planning. PMH Care Pathways can be found at: http://ccnc.care/pathways.
CCNC uses Medicaid claims, birth certificates, and risk screening data to produce quarterly metrics. Measurement of clinical quality reflects program priorities, such as low birth weight, timeliness of entry to prenatal care, postpartum care, and risk screening rate.