Pregnancy Medical Home: Improving Maternal & Infant Outcomes in the Medicaid Population
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.
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
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.