Earlier this year, the Center for Medicare and Medicaid Innovation (CMMI) announced Strong Start, a major federal initiative to improve birth outcomes among Medicaid enrollees. (Letters of Intent are now due May 11, 2012.) The initiative includes a funding opportunity for three innovative models of prenatal care delivery that show promise for reducing preterm births. Two of the three models have national organizations that define and promote them: group prenatal care models like CenteringPregnancy and prenatal care in birth centers, a model promoted by the American Association of Birth Centers. The third model has left some people scratching their heads: Maternity Care Homes. What is a Maternity Care Home and, more importantly, what changes do practices have to make to become one?
The purpose of this article is to foster awareness and discussion about Maternity Care Homes and to encourage Strong Start applicants to advance this model. The article will answer common questions about Maternity Care Homes, with a focus on implementation. If you have other questions, please leave them in the comments.
Who is promoting the concept of Maternity Care Homes and what exactly are they promoting?
The Maternity Care Home concept has broad support from payers and maternity care reform advocates. The 2010 multi-stakeholder Blueprint for Action called for ensuring that “every woman has access to a Woman- and Family-Centered Maternity Care Home.” Several states have begun pilot Maternity Care Home projects, while at the federal level Maternity Care Homes have been proposed in The Quality Care for Moms and Babies Act (HR 3620 and S 1969) and, most recently, Strong Start. Maternity care homes are defined broadly in federal programs to enable implementation models that are appropriate for local needs and resources and enable local innovation. State and local programs define Maternity Care Homes and set program eligibility around more focused approaches that vary from state to state. Some features of Maternity Care Homes are common across all definitions:
- continuity of care from a primary clinician who accepts responsibility for providing and/or coordinating all health care and related social services during a woman’s pregnancy, childbirth, and postpartum period
- commitment to continuous quality improvement, patient safety, and evidence-based practice
- commitment to woman-centeredness and a positive experience of care
- timely access to appropriate care and information
But what does a Maternity Care Home look like “in real life”?
Unlike Patient-Centered Medical Homes (of which Maternity Care Homes are an adaptation), standard-setting bodies and recognition programs for Maternity Care Homes do not yet exist. Therefore, it is difficult to compile a checklist or similar tool to define the specific features and elements that make a practice a Maternity Care Home. However, there are many processes, tools, and policies that foster and facilitate the above commitments. Examples include:
Primary clinician responsible for providing and/or coordinating care
- Each woman can choose or is assigned a specific doctor, midwife, or nurse-practitioner responsible for her care (a primary maternity care provider).
- Each woman can access her primary maternity care provider directly by phone, secure email, or web portal.
- There are written policies for collaboration and referral to higher levels of care as needed.
- The practice employs or has collaborative relationships with care guides or case managers to help women navigate health care and social services.
- The practice employs or has collaborative relationships with nutritionists, behavioral health specialists, health educators, genetics counselors, doulas, and other health workers and support personnel.
- The practice uses electronic tools to track lab results and referrals, reconcile medications, and generate reminders for health screenings.
- After birth, care of the woman and newborn are coordinated and include high-quality assistance with breastfeeding.
- Prenatal and postpartum care are coordinated with pre- and inter-conception care and services.
Continuous quality improvement, patient safety, and evidence-based practice
- The practice uses nationally endorsed performance measures to monitor and improve care processes and outcomes.
- All women are screened, using appropriate and valid screening tools, for depression, risk of preterm birth, nutritional problems, smoking, substance use, intimate partner violence, and/or other conditions, behaviors, and circumstances as appropriate.
- Evidence-based guidelines, checklists, algorithms, and other clinical decision support tools are used to guide safe and appropriate care, and are reviewed periodically and kept up to date.
Commitment to woman-centeredness and a positive experience of care
- Care and information are provided in the woman’s preferred language and at the appropriate literacy/numeracy level.
- Care plans, including birth plans, reflect each individual woman’s goals and expectations.
- Visits provide adequate time to address women’s questions and concerns.
- Clear, user-friendly tools (e.g. secure web portals) or policies are in place to assist women with the full array of care and logistical needs, such as prescription refills, referrals, medical leave forms, appointment scheduling, and billing and insurance issues.
- The practice solicits feedback from women (e.g. through patient experience surveys) and uses this data to make improvements.
- Family members and other companions are included in the woman’s care.
- All patient communication is documented in the medical record.
- Women receive notification of all lab results and have easy and timely access to their complete medical records.
- The care team offers home visitation.
- Tools and communication processes support shared decision making based on the best available evidence and incorporating women’s preferences, concerns, and individual circumstances.
Timely access to appropriate care and information
- Women can make same-day appointments for problem visits.
- Appointments begin on time.
- The practice tracks and minimizes the time between when a woman requests an appointment and when one is available.
- Clearly communicated, user-friendly policies enable access to a clinician after hours.
- Information about benefits, risks, and alternatives for tests and procedures is provided well in advance of decision-making whenever possible
- The timing of birth is determined by maternal–fetal physiology or clear medical indication, not by time pressures exerted externally.
Does my practice have to offer all of those enhancements to be a Maternity Care Home?
No. As noted above, no standards yet exist for Maternity Care Homes and local considerations and resources must be considered in planning and implemention. The Strong Start program and a demonstration program described in the Quality Care for Moms and Babies Act each require eligible practices to choose from among an array of practice enhancements.
Insurers do not pay for all of these practice enhancements and special services. How is my practice going to afford to make these changes, especially considering recent cuts in Medicaid reimbursements in many states?
Current payment systems reward poorly coordinated, procedure-intensive care. Adopting systems to enable better, more coordinated care can be costly and reduce productivity in the short term. Practices also need ongoing resources to support time-intensive processes like responding to emails and engaging in shared decision making.
For these reasons, the federal government is trying to stimulate adoption of woman-centered tools and care practices through innovation grants like Strong Start, which will cover costs not reimbursed by Medicaid. Federal incentives for adoption of qualified health information technology will also defray some of the upfront costs. In addition, state Medicaid programs and some other payers have used a variety of payment incentives to encourage participation in Maternity Care Home programs. These incentives include per-patient lump sums paid up front or, more commonly, incentives that reward reporting and improving on nationally endorsed performance measures. Thus, care processes that improve outcomes will translate into higher reimbursement for participating providers and practices. It is likely that future maternity payment reforms will intensify pay-for-performance trends, link them directly to reduction of priority outcomes like preventable cesareans and neonatal intensive care admissions, and incorporate incentives for improved “experience of care,” as measured by patient experience surveys.
What Maternity Care Home programs have already been developed?
- North Carolina has a Pregnancy Medical Home program aimed at reducing preterm births and primary c-sections.
- A midwife-led, physician-owned birth center practice in Minnesota has developed a Maternity Care Home program and is also partnering with payers to integrate comprehensive payment reform.
- Connecticut is developing a pay-for-performance Pregnancy Care Home program combining collection and reporting of performance data with home visitation by nurses and human services specialists who administer appropriate risk screenings and coordinate necessary social services. No information is currently available online about this state program.
Where can I find tools to help plan and implement a Maternity Care Home?
Toolkits and other resources for Maternity Care Home implementation do not yet exist. However, some tools designed to help primary care practices become patient-centered medical homes (PCMH) are likely to be useful to practices that want to adopt a Maternity Care Home model. For example, the American Congress of Obstetricians and Gynecologists offers a self-assessment tool to help Ob-Gyn practices determine if they meet PCMH standards. The Agency for Healthcare Research and Quality provides a robust set of tools and white papers on various aspects of PCMHs. The National Committee for Quality Assurance, which recognizes PCMHs has additional tools and resources and the Patient-Centered Primary Care Collaborative offers more resources, including reports, webinars, and a national stakeholder conference. The TMC Toolkit Directory includes additional patient- and family-centered care toolkits that can be adapted or applied to maternity care.
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