In our last blog, we discussed the problem of premature birth and maternal mortality in the United States, especially in the Medicaid population. An important strategy for managing this is providing care management services for those mothers at high risk for poor outcomes. What is care management?

Care management is a set of activities intended to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions. These efforts have demonstrated potential to improve quality and control costs for patients with complex conditions (Robert Wood Johnson Foundation, 2018). Generally, pregnancy care management services are provided by a team that can include a nurse, social worker, dietician, and community health workers who all work in conjunction with a mother’s provider (physician, nurse practitioner, midwife, etc.). Nurses talk with a pregnant mother and complete an assessment to identify areas where the mother might need some extra help. Topics might include everything from confusion about what medications she should be taking to a lack of stable housing. These types of struggles can have a major impact on the ability to have a healthy pregnancy. “Homeless women experience a higher number of adverse birth outcomes when compared to the general population. Homeless women are 2.9 times more like to have a preterm delivery and 6.9 times to have a low birth weight infant” (ACOG, 2018).

In general, Medicaid plans provide pregnancy care management services by identifying pregnant mothers and triaging them for high-risk care management. This identification process can come from several different sources: a referral from the provider, a state report, claims data, or referrals from other plan programs (i.e. utilization management). Using these methods, identification can be delayed or even missed altogether creating a missed care management opportunity. In addition, even when identification is timely, the care team often lacks information about all the conditions a mother has that can impact her pregnancy.  This makes it extremely difficult to understand which mothers are at highest risk and in need of care management services.

At Lucina Health, we have developed maternity-specific analytics that allow us to identify more than 70% of pregnant women in the first and second trimester, and risk-score all women throughout pregnancy.  The information is shared with a dedicated care team helping these women with interventions to manage risk and extend gestational days.  Our effort is working.  Working with a Medicaid Managed Care Organization in Kentucky over the last year, we have achieved a 12% decrease in pre-term births in the past 18 months, and we are just getting started.

Below is a comparison of 2 real mothers and the impact care management can have.

Both women had similar conditions, but Mom A was not identified by the plan until after her baby was born so she did not receive care management services.

Mom AMom B
Known Prenatal Risk FactorsDepressionOpioid DependenceTobacco Use DisorderDrug DependenceDepressionObesityTobacco DependenceAdult MaltreatmentGenitourinary InfectionsInsomniaSexually Transmitted Infections
First Prenatal Visit19 Weeks Gestation6 Weeks Gestation
Care Manager InterventionsN/AMother wanted to go to inpatient detox but was afraid she would lose her apartment and job. Nurse made a referral to social worker who provided assistance. Mother successfully completed inpatient detox.Completed therapy for tobacco dependenceReferred to and began in-home mental health treatmentReferred to lactation consultant and is breastfeeding babyAttended postpartum visit and was prescribed birth controlReferred to other community agencies that support mothers and babies
Baby’s Gestational Age at Birth33 Weeks39 Weeks
Days in Neonatal Intensive Care Unit21 Days, Baby with Neonatal Withdrawal Symptoms0 Days, No Neonatal Withdrawal Symptoms
Billed Cost for First Year of Life$117,499$6,536

For more information on how you can engage Lucina Health to help more mothers and babies, e-mail us at or call 502.234.7200.Although this is just one example, it demonstrates the impact that care management, provided early not only has on birth outcomes but on cost. Thanks to care coordination this nurse care manager provided, this baby was not only born healthy but also now has a healthy mother, giving that family the best start possible.

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