Many health systems and states in the US attempting to scale Triple Aim approaches to care implemented elements of the patient-centered medical home (PCMH) as a foundation in their work. The PCMH model is designed to track patients over time, be more patient-centered, and coordinate multiple services and supports necessary to provide proactive care focused on health. Adaptations of the PCMH model have also arisen, targeted to specific populations such as cancer care, geriatrics, and obstetrics and gynecology.
Over the past year, IHI has worked to understand optimal population-focused models for maternity care in the US, especially for low-income populations. Given the broad longitudinal impact of early health interventions and outcomes, the opportunity to impact the Triple Aim overall, as well as the negative consequences of suboptimal maternity care for the US health care system and for society in general, it is of utmost importance to improve care for this population.
While the maternity medical home model is relatively early in development in most parts of the US, some early evidence exists of its positive impact on birth outcomes. Further, the maternity medical home offers a means to organize and anchor other interventions, and ensure coordination of often fragmented social, behavioral, and health services.
Defining the Maternity Medical Home
According to the Joint Principles of the Patient Centered Medical Home, the patient-centered medical home includes seven key principles: a personal physician; a physician-directed medical practice; whole-person orientation; coordinated and integrated care; a quality and safety focus; enhanced access; and payment that recognizes the value offered to patients by the model.
The maternity medical home adopts these principles to perinatal care. Components include the clinical aspects of care, as well as services that address the behavioral, psychological, and social factors that a woman may face during pregnancy and which can complicate efforts to achieve good birth outcomes.
The maternity medical home incorporates several key operational elements, including:
- A standardized risk assessment to identify a woman’s needs;
- A focus on early entry into prenatal care (first trimester);
- Care coordination by a nurse, social worker or other health care professional to ensure that a woman receives all needed services during pregnancy;
- Standardized care pathways that target common risk factors for poor birth outcomes and ensure that each woman receives all recommended care;
- Elements of enhanced access such as expanded hours and improved ability to contact providers; and
- Patient-centered care, including shared decision-making about key aspects of perinatal care (such as where and how the delivery should take place).
Many maternity medical home models are also increasing their longitudinal focus, either serving the woman across her childbearing years or working to facilitate the transition to well woman care provided in other settings.
Efforts to Scale the Maternity Medical Home Are Gaining Ground
North Carolina’s Pregnancy Medical Home Program
North Carolina has been a leader in development of the maternity medical home model. Launched in 2011, the state’s Pregnancy Medical Home (PMH) model centers on a partnership between Community Care of North Carolina, a statewide not-for-profit organization that serves as the state’s primary case management program for Medicaid, and the North Carolina Division of Medical Assistance, the state Medicaid agency. The program has a primary focus on reducing the rate of preterm birth, and the model includes a number of key mechanisms:
- Standardized medical, obstetric, and psychosocial risk assessments for all pregnant women administered at the first prenatal visit;
- Collaboration between each PMH practice and a care manager from the local department of public health (typically a nurse or social worker);
- Involvement of practices in 14 regional networks in the state, led by obstetrician-nurse dyads who provide education, support, and technical assistance and who represent the maternity care providers from each network at the state level;
- Dedicated care pathways for conditions like hypertension and substance use; and
- Financial incentives for participation, including payments for prenatal risk screening and postpartum visit completion and an enhanced reimbursement rate for vaginal deliveries.
As part of the model, practices also agree to work toward improvement goals like using progesterone to reduce preterm birth, increasing the postpartum visit rate, eliminating early elective deliveries, and reducing the primary cesarean delivery rate.
The program includes the diversity of perinatal care providers in the state, such as OB/GYN offices, family medicine practices, academic medical center high-risk OB clinics, midwifery practices, county health department clinics, and federally qualified health centers. Nearly all the state’s providers who care for the pregnant population participate in the program.
Wisconsin’s OB Medical Home Program
Wisconsin has taken a different approach from North Carolina, relying on Medicaid HMOs as a mechanism to scale the medical home approach. The state’s OB Medical Home Program began in 2011 in Southeast Wisconsin, and has since spread to two additional counties. Unlike the North Carolina program, the Wisconsin program has strict eligibility criteria based on local risk factors for adverse birth outcomes such as young maternal age (less than 18 years), homelessness, and prior poor birth outcomes.
HMOs recruit clinics to participate, and Medicaid pays the HMO for each woman enrolled that meets the specific criteria. The woman receives a set of required minimum services, including 10 prenatal visits, and the HMO provides additional payment for positive birth outcomes such as term pregnancy and normal birthweight. OB practices can receive support from prenatal care coordination providers to support care coordination. Community-based organizations, social service agencies, public health agencies, HMOs, and medical providers can all provide prenatal care coordination services under a separate contract with the state.
The Center for Medicare and Medicaid Innovation’s Strong Start Initiative
The Strong Start for Mothers and Newborns Initiative includes the maternity medical home as one of three care models that received funding in 2012 for testing and development, part of an innovation effort rooted in the Affordable Care Act. Thirteen organizations received funding to start maternity medical home models in thirteen states. These providers have taken diverse approaches to implementing the model, and many will likely continue to use the model even after the end of the demonstration. For example, in Missouri, Signature Medical Group's approach includes a standardized risk assessment, the use of a dedicated nurse navigator to coordinate care and follow patients between visits, and the use of a social worker to conduct home-based assessments and offer resource referrals and coordination.
Early Evidence Is Showing a Positive Impact
While evaluation of the maternity medical home model in improving birth outcomes is still in its initial stages, some early findings point to benefits for women and babies receiving care in programs designed on these models. For example, research published in 2015 in North Carolina found that since the inception of the pregnancy medical home program in 2011, the state has seen a 6.7 percent decrease in the rate of low birthweight babies in the Medicaid population. An Oregon pilot of a maternity medical home model found increased rates of depression screening.
Part of the appeal of the maternity medical home model is that it can serve as an anchor for other models to improve perinatal care — such as behavioral health integration, substance abuse treatment, and even models such as group prenatal care. The increasing support for this approach signals a desire to move beyond a purely medical approach to pregnancy care to one that provides whole-person-oriented care that is focused on broader population health management.
While technical specifications for a national maternity medical home model do not yet exist (e.g., for accrediting purposes), these models together reveal the approaches necessary to apply the medical home concept in the pregnancy context.
Jeffrey Rakover is an IHI Research Associate and a member of the IHI Innovation Team. To learn more about the work described above, register for the IHI National Forum (December 10-13, 2017, in Orlando, FL).
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