Pregnancy Medical Home

Overview

When considering the prevalence of preterm birth, low birth weight and infant mortality, North Carolina has repeatedly ranked in the top quartile in comparison to other states. In 2009, Medicaid paid for over 50 percent of the nearly 127,000 births in North Carolina. The Pregnancy Medical Home (PMH) program was born out of a collaborative effort among Community Care of North Carolina, NC Division of Medical Assistance (DMA), NC Division of Public Health (DPH) and local health departments (LHDs), to improve birth outcomes and control costs associated with high rates of low birth weight and preterm births.

 

Each Community Care Network, such as Community Care of Wake and Johnston Counties, provides an OB team, consisting of an OB nurse coordinator and an OB physician champion to recruit, educate and support the Pregnancy Medical Home practices. Additionally, each practice is assigned a Pregnancy Care Manager through the public health facilities of Wake County Human Services and Johnston County Health Department. These individuals focus on developing individualized care plans for those patients with identified risk factors. Any practice or clinic that provides prenatal care to Medicaid recipients is eligible to become a Pregnancy Medical Home. In exchange for adhering to specific expectations, the PMH practices are provided financial incentives, which drive quality improvements and improved pregnancy outcomes; ultimately, decreasing Medicaid pregnancy related expenditures.

 

Practice Information and Tools

  • PMH Brochure
  • Special PMH Bulletin
  • PMH Orientation
  • Risk Assessment-Initial - English | Spanish
  • Risk Assessment-Follow up - English | Spanish
  • Sample Postpartum Visit Form
  • Adult depression screening tool (PHQ-9) - English | Spanish
  • Postpartum depression screen - English | Spanish | Scoring
  • DMA Update on 17P
  • 17P Information Sheet
  • PCP Change form - Wake County | Johnston County

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    Patient Education

  • PMH information sheet - English | Spanish
  • Smoking Cessation

     

    Pregnancy Care Management Resources

  • Priority risk criteria for pregnancy care management
  • OB (Pregnancy) Care Management Standardized Plan
  • Recommended process for provision of care to pregnant patients who are currently receiving Primary Care Management
  • Coordination Between CCNC and Pregnancy Care Management
  • Guidance for implementing goals to address medical conditions that contribute to poor birth outcomes
  • Summary of important points from pregnancy webinar presented by Vienna Barger
  • Motivational Interviewing
  • OBCM Statewide Referral Directory
  • OB Nurse Coordinator Map
  • Network OB Coordinator Contacts
  • PCM Referral Form - Wake County | Johnston County

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    CMIS (Case Management Information System)

  • Process for training new Pregnancy Care Managers
  • Process for staff to access their caseload
  • Process for finding and assigning patients who are not in CCWJC
  • CMIS documentation reminders
  • Request to add patient into CMIS
  • Request to add patients to CMIS due to duplicates
  • CMIS Contact Resources for Wake and Johnston Counties

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    Measures

  • Performance Indicators

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    Links

  • MomBaby
  • NC Healthy Start - English | Spanish
  • Every Woman
  • NC Division of Medical Assistance
  • NC Division of Public Health
  • Community Care of North Carolina
  • Provider Portal Demo
  • Provider Portal

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