1.2 Postpartum Continuity of Care

Michigan. MIHP covers all Medicaid-eligible pregnant women and infants until the age of 18 months for home visits.335 This program is part of partnerships with managed care organizations, and health plans are obligated to refer every pregnant woman covered under their plans to MIHP.336 MIHP has demonstrated positive effect on prenatal and postnatal care, including increased adequate prenatal care and increased timely postnatal care. It has also been shown to reduce infant deaths, both amongst Black populations and other populations of color.337

Additional Considerations

In the short-term, NC Medicaid should increase the role for CHWs in maternal health by integrating them into PMP. NC DHHS operates the Community Health Worker Initiative with the goal of “establish[ing] a sustainable infrastructure that acknowledges the value of CHWs, supports their professional identity, and integrates their role in the healthcare team”.338 NC DHHS should consider how it can leverage the Community Health Worker Initiative to deploy CHWs to maternal home visiting programs like PMP, similarly to how NC DHHS deployed over 400 CHWs to 55 counties.339

In the medium-term, NC DHHS should support funding increases to home visiting programs to expand their capacity to provide services through additional locations or staffing. Programs like NFP and HFA operate on a combination of federal, state, and/or private funding.

In the longer-term, NC Medicaid should expand eligibility for home visit case management to all pregnant and postpartum women on Medicaid.

NC Medicaid should improve access to and continuity of care during the postpartum period.

Implementation: • NC Medicaid should integrate postpartum care into well-child visits where the birthing mother is present. • NC Medicaid should utilize care coordinators for all Medicaid-eligible postpartum women to integrate them into medical homes.

• NC Medicaid should specifically offer postpartum home visits to all Medicaideligible women.

North Carolina Context

Continuity of care throughout pregnancy and postpartum is key to improving maternal and infant health outcomes.340 Acknowledging the importance of the postpartum period, North Carolina’s new budget includes a permanent expansion of pregnancy Medicaid to one year postpartum. Despite this progress, ensuring women, and specifically women of color, actually receive quality postpartum care should remain a top priority. In North Carolina, postpartum visit attendance among Medicaid enrollees is troublingly low. A study of six Atrium Health hospitals in Mecklenburg County in 2014-15 found that 90 percent of mothers with commercial insurance, but only 50 percent of mothers with Medicaid, received a six-week postpartum checkup.341 Notably, a majority of the mothers insured by Medicaid were women of color—49 percent identified as Hispanic and 32 percent identified as non-Hispanic Black.342

Multiple factors inhibit attendance at postpartum visits. These include challenges in caring for a new baby, lack of transportation, and limited access to childcare (see Transportation Section in Part I).343 Another major challenge is scheduling around well-child visits. Mothers already have to find time to bring their children in for well-child visits, making it difficult to schedule additional visits for their own postpartum care.344 When mothers do attempt to schedule postpartum appointments, they may lack information on their type of coverage and who to call to schedule an appointment.345 Furthermore, mothers often see different providers during prenatal, birth, and postpartum periods, which can inhibit the creation of trust between women and their providers.346

Evidence

Postpartum Care During Well-Child Visits One method to improve postpartum care attendance is to integrate care within well-child visits. Research shows women with Medicaid are more likely to attend well-child visits than to attend their own postpartum visit. A study of women in a Chicago hospital found that 86 to 94 percent support this kind of care integration.347 The IMPLICIT (Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques) network—which has more than 20 sites across several states, including North Carolina— provides interconception care at well-child visits. This care includes screening and counseling focused on smoking, depression, contraception, and multivitamin consumption.348 The IMPLICIT interconception care program offers various billing options through Medicaid, depending on the service provided. For example, counseling on smoking and depression can potentially be billed under the child’s benefits—since these issues impact the child—or the mother’s benefits. Counseling on family planning or multivitamin consumption can be billed under specific codes in the mother’s coverage if she is enrolled in Medicaid.349 Additionally, under Virginia’s BabyCare program, providers are reimbursed for conducting behavioral health screenings for mothers at well-child appointments under the infant’s insurance, which help uncover issues such as mental health, domestic violence, or substance use.350

Navigating Postpartum Care Through Care Coordinators and Pre-Discharge Postpartum Care Plans Care coordination that supports mothers in creating postpartum care plans and scheduling appointments may improve postpartum care. A study at a Medicaid-based clinic in Chicago evaluated the impact of a patient navigator who provided appointment scheduling assistance, referrals to other services, and information on contraception and breastfeeding. The study found positive associations with postpartum checkups by 12 weeks postpartum, as well as receipt of contraceptive methods and postpartum depression screening.351 Mothers should receive a postpartum care plan from an interdisciplinary provider team before hospital discharge or within 24 hours after discharge.352 The postpartum care plan should include information on the following: • Assignment to a medical home and a point of contact. • Plans for a postpartum follow-up visit as well as any other follow-up appointments for other medical conditions. • Information regarding social services, breastfeeding, contraception, chronic conditions and mental health.353

Continuity of care can be improved by facilitating contact between postpartum and prenatal providers or ensuring the same care coordinator through pregnancy and postpartum.354

Postpartum Home Visits As discussed in the above section (see Home Visits), home visits are a key pathway to provide care management, especially for low-income mothers of color. The Maternal Infant Health Program (MIHP) in Michigan covers all Medicaideligible pregnant women and infants until the age of 18 months for home visits.355 New Jersey and Oregon have implemented universal