Transcript Access and Utilization of Early Prenatal Care and

The Circle of Care for Women
EARLY PRENATAL CARE
AND
MEDICAL HOMES FOR
NON-PREGNANT WOMEN
Acknowledgements
 This training was developed by the North Carolina
Preconception Health Campaign, a program of the March
of Dimes North Carolina Chapter, under a contract and in
collaboration with the North Carolina Division of Public
Health, Women’s Health Branch.
 This material was developed through support provided by
the U.S. Department of Health and Human Services, Office
of the Assistant Secretary for Health, Office of Adolescent
Health (grant #SP1AH000004).
Acknowledgements
 Many thanks to these agencies and individuals for their
generosity in sharing their resources in the area of early
prenatal care and medical homes for women:
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

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North Carolina Division of Public Health, Women’s Health Branch
Merry-K Moos, FNP, MPH, FAAN
Alvina Long Valentin, RN, MPH
Sarah Verbiest, DrPH, MSW, MPH
 Specific resources used to guide the development of this
training:

The National Preconception Curriculum and Resources Guide for
Clinicians (Module 1: Preconception Care: What it is and what it
isn’t)
Young Moms Connect
 Brings together community partners to address challenges
faced by pregnant or parenting teens using collaborative,
multi-faceted strategies
 One component of Young Moms Connect is training for
health care providers on six maternal and child health best
practices
Maternal & child health best practices
 Early entry and effective utilization of prenatal
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



care
Establishment and utilization of a medical home
(for non-pregnant women)
Reproductive life planning
Tobacco cessation counseling using the 5 A’s approach
Promotion of healthy weight
Domestic violence prevention
Objectives
 Increase awareness about the relationship between
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preconception health, early prenatal care and a medical
home
Increase knowledge about current status of prenatal care
among young mothers
Assess local prenatal care services and early entry barriers
Increase awareness about the importance of primary care
medical homes for women of reproductive age
Develop strategies to link young women, especially in the
postpartum period, to medical homes
What is preconception care?
 Identification of modifiable and non-modifiable risk factors
for poor health and poor pregnancy outcomes before
conception
 Timely counseling about risks and strategies to reduce the
potential impact of the risks
 Risk reduction strategies consistent with best practices
CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules
Components of preconception care
 Giving protection

(eg.: folic acid,
immunizations)
 Managing conditions

(eg.: diabetes, maternal PKU,
obesity, hypertension,
hypothyroidism, STIs, sickle
cell)
 Avoiding exposures
known to be teratogenic

(i.e.: medications, alcohol,
tobacco, illicit drugs)
CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules
“Opportunistic” care
 Preconception care is for
every woman of
childbearing age every
time she is seen
 Every woman, every time
CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules
Every woman, every time
 Young women who are at
risk of pregnancy
 Young women who are
pregnant
 Young mothers who are
postpartum
 Young mothers who are
between pregnancies
From linear care…
Moos, MK. Connecting the Dots: Health Status Before Pregnancy and Pregnancy Outcomes. 2011
…to a circle of care
Opportunistic
preconception
health care
Transition to
medical home
Healthy
outcomes
Improved
preconception
health
Early
prenatal
care
Be healthy before pregnancy
 Message for all women of
childbearing age:



Remember, being in the best
physical, emotional and
financial position BEFORE
pregnancy is best
Make sure your future
pregnancies are planned and
intended
Prenatal care should start as
early as possible in
pregnancy
Early prenatal care
 Why is early prenatal
care important?
 Recommended prenatal
care schedule:
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Weeks 4-28: 1 visit per
month
Weeks 28-36: Visits every 2
weeks
Weeks 36-birth: Weekly
visits until delivery
Components of prenatal care
 Review of:
 Individual medical history
 Obstetrical and gynecological history
 Family history
Components of prenatal care
 Screening, referral and/or treatment for:
 Genetic risks
 Infectious disease
 Chronic disease
 Psychosocial issues
 Environmental issues
 Immunizations
 Nutritional concerns
Components of prenatal care
 Laboratory studies
 Vital signs
 Maternal assessment
 Fetal assessment
 Patient education
Prenatal development
Weeks gestation
from LMP
4
Most susceptible
time for major
malformation
5
6
7
8
9
10
11
12
Central Nervous System
Heart
Arms
Eyes
Legs
Teeth
Palate
External genitalia
Ear
Missed Period
Mean Entry into Prenatal Care
CDC National Preconception Health Curriculum and Resource Guide for Clinicians, 2008
Importance of prenatal care
 Adequate use of prenatal care associated with:
 Healthy birth weights
 Decreased risk of preterm delivery
 Inadequate use of prenatal care associated with increased
risk of:
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
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
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Low birth weight
Preterm delivery
Neonatal mortality
Infant mortality
Maternal mortality
Kiely JL, Kogan MD. From data to action: Reproductive health of women (Prenatal Care). Pp. 105-118. 1994
Young mothers are at higher risk
 Teens are least likely of
all maternal age groups
to get early and regular
prenatal care1
 Teens are at greater risk
than women over age 20
for pregnancy
complications such as
premature labor, anemia
and high blood pressure2
 Teens are more likely
than women over age 25
to smoke during
pregnancy3
1. National Center for Health Statistics, final natality data, 2007
2. American College of Obstetricians and Gynecologists. Especially for Teens: Having a Baby. Patient Education Pamphlet, August 2007
3. Centers for Disease Control and Prevention. Preventing Smoking and Exposure to Secondhand Smoke Before, During and After Pregnancy. October 3, 2007
Late entry into prenatal care
NC Women Entering Prenatal Care
in the Third Trimester or not at all
30%
 Mothers with unintended
pregnancies are more
likely to enter into
prenatal care later in
their pregnancies
25%
20%
15%
10%
5%
0%
Unintended
pregnancy
Intended
pregnancy
North Carolina State Center for Health Statistics, Risk Factors and Characteristics for 2009 Resident Live Births
Mothers receiving prenatal care in the first trimester
2004-2008, live births
North Carolina
82%
Bladen
72%
Nash
76%
Onslow
90%
Rockingham
85%
Wayne
71%
NC State Center for Health Statistics, 2004-2008. Trends in Key Health Indicators
Mothers not receiving prenatal care in the first
trimester in North Carolina, 2008
 21% of mothers surveyed did NOT access first trimester
prenatal care
 Rates for not receiving care in the first trimester are highest
for:
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Young mothers (35% < 20 years, 31% 20-24 yrs)
African-American (34%) and Hispanic mothers (31%)
Unmarried women
Less education
Lower income levels
NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System
Access to prenatal care
North Carolina mothers who reported they did not receive
prenatal care as early as they wanted
 31% of mothers < 20 years of age
 25% of mothers age 20-24 years
 Half of all young mothers reported experiencing barriers to
prenatal care
NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System
Barriers to prenatal care in North Carolina
Barrier
Teens
Ages 20-24
Did not want the pregnancy known
16%
16%
Couldn’t get an appointment earlier
15%
21%
Didn’t have my Medicaid card
15%
16%
Transportation
13%
9%
No money or insurance
12%
22%
NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System
Prenatal care for African-American mothers
in North Carolina
 Less likely to start prenatal care in first trimester
 70% of prenatal care is paid by Medicaid
 2/3 enroll in WIC (66%)
 1 in 3 African-American mothers were already enrolled in
Medicaid prior to pregnancy (30%) compared to white
mothers (9%)
NC PRAMS Fact Sheet April 2011. NC African American Maternal Health
Prenatal care for African-American mothers
in North Carolina
 Significantly more likely
to experience at least one
prenatal barrier
compared to white
mothers (48% vs. 37%)
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
1 in 5 reported they were not
able to get an appointment
earlier in pregnancy
1 in 6 reported having no
insurance
NC PRAMS Fact Sheet April 2011. NC African-American Maternal Health
Not just early but adequate
 Young Moms Connect has two prenatal care goals:
 Making sure young women enter prenatal care during the first
trimester
 Making sure young women continue to follow the recommended
prenatal visit schedule
 Measures of adequacy of prenatal care
 Kotelchuck Index: Looks at month of prenatal care initiation and
total number of visits (compares number of expected visits to actual
number of visits). Classifies as: inadequate, intermediate, adequate
and adequate plus.
 Kessner Index: Looks at weeks of gestation and total number of
visits. Classifies as: inadequate, intermediate and adequate.
Adequacy of prenatal care, Kessner Index, 2009
Number of
Births
Adequate
Intermediate
Inadequate
North
Carolina
126,785
78%
16%
5%
Bladen
378
74%
18%
7%
Nash
1,269
68%
23%
8%
Onslow
4,058
86%
11%
3%
Rockingham
1,048
87%
10%
3%
Wayne
1,661
63%
29%
8%
NC State Center for Health Statistics, 2009 NC resident births by county and Kessner Index
Location of prenatal care for young women
Care provider
Teens
Ages 20-24
Private practice/HMO
39%
47%
Health department
28%
29%
Hospital clinic
15%
16%
Other
18%
8%
NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System
Preconception health & early prenatal care
Opportunistic
preconception
health care
Transition to
medical home
Healthy
outcomes
Improved
preconception
health
Early
prenatal
care
Important components of prenatal care
and preconception health
 Identification & treatment
of sexually transmitted
infections
 Assessment of medication
use
 Identification of
environmental risks (e.g.
tobacco use, lead
exposure, varicella
exposure)
 Achieving and/or
maintaining healthy
weight
Sexually transmitted infections & pregnancy
 Chlamydia
 Untreated can cause prematurity, pink eye, and breathing problems
for the baby
 Genital Herpes
 25% of American women are infected (most do not know –
asymptomatic); can be transmitted during a vaginal delivery and can
cause blindness, brain damage and death of baby
 HPV-Genital Warts
 Over 6 million new infections/year in United States; can be
uncomfortable during pregnancy
 Bacterial Vaginosis
 May increase a woman's chances of premature rupture of
membranes and preterm delivery
Cunningham, F.G., et al. Sexually Transmitted Diseases, in Williams Obstetrics, 22nd Edition. New York, McGraw-Hill Medical Publishing Division, 2005, pages 1301-1325
Workowski, K.A., Berman, S.M. Sexually Transmitted Disease Treatment Guidelines, 2006. Morbidity and Mortality Weekly Report, volume 55, RR11, August 4, 2006
Sexually transmitted infections & pregnancy
 Gonorrhea
 Untreated it can cause blindness, joint infections and life threatening
blood infections for the baby
 HIV/AIDS
 Untreated – higher risk of transmission to the baby
 Syphilis
 Untreated can cause blindness, brain damage or death for baby in
addition to prematurity, stillbirth and congenital malformations
 Hepatitis B
 Untreated can infect the baby at delivery and can later cause liver
disease or liver cancer; Also increases risk for infant to become a
Hepatitis B carrier
Workowski, K.A., Berman, S.M. Sexually Transmitted Disease Treatment Guidelines, 2006. Morbidity and Mortality Weekly Report, volume 55, RR11, August 4, 2006.
Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance 2005 Supplement, Syphilis Surveillance Report. December 2006.
Gonorrhea and chlamydia in North Carolina
 59% of new gonorrhea cases in 2010 were to women
 80% of new chlamydia cases in 2010 were to women
 Both disproportionately affect African-American women
 High rates among ages 15-24 year-olds
2010 STD/HIV Surveillance Report. Communicable Disease Branch, N.C. Division of Public Health
HIV in North Carolina
 In 2009, 26% of new HIV cases were to women
 Rate per 100,000 population
 African-American women, 38.7
 White women, 2.7
2009 STD/HIV Surveillance Report. Communicable. Disease Branch, N.C. Division of Public Health
HIV disease cases by county
2007-2009 average
County
Rank among 100
NC counties
Cases per 100,000
residents
Bladen
10
26
Nash
26
18
Wayne
35
14
Rockingham
61
9
Onslow
69
7
2009 HIV/STD Surveillance Report. Table 2. Communicable Disease Branch. NC DHHS
Medication
 Because almost half of all
pregnancies in North
Carolina are unintended,
medication use should be
monitored carefully
during women’s
childbearing years
Medications and pregnancy
 Medications known to cause serious birth defects if taken
during pregnancy:
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
Isotretinoin
Thalidomide
 Medications for the following conditions should be closely
monitored for women of childbearing age:
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Asthma
Epilepsy
High blood pressure
Depression
U.S. Centers for Disease Control and Prevention, retrieved July 2011
Environmental risks
 Several environmental risks are associated with increased
risk for poor maternal and/or infant outcomes and should
be addressed as early as possible during prenatal care and
throughout pregnancy
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Tobacco use
Alcohol use
Illicit drug use
Exposure to some toxins (e.g. lead exposure)
Experience high levels of stress
Experiencing violence
Maternal smoking during pregnancy
 Smoking during
pregnancy is the single
most modifiable risk
factor for poor birth
outcomes
 Increased risk for mother
of:





Ectopic pregnancy
Preterm premature rupture
of membranes
Placental complications
Preterm delivery
Spontaneous abortion
ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011
Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes Nicotine Tob Res, 2004
Maternal smoking during pregnancy
 Increased risk for child of:
 Low birthweight (causal association – twice as likely in smokers)1
 Sudden infant death syndrome1
 Childhood respiratory illnesses2
 Learning disabilities and conduct disorders1
 If it were possible to eliminate smoking during pregnancy
entirely, the infant mortality rate in North Carolina would
drop 10-20%.3
1Women
and smoking: A report of the Surgeon General. U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC,
2001
2Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and
Immunology 79(1): 80-84. 1997
3Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, 1999. SCHS Studies No. 135. Raleigh,
NC: North Carolina State Center for Health Statistics; 2002
Smoking during pregnancy
 Nationally between 12-20% of all pregnant women report
smoking during pregnancy
 Current clinical guidelines:
“Whenever possible pregnant smokers should be offered
person-to-person psychosocial interventions that exceed
minimal advice to quit. Clinicians should offer effective
tobacco dependence interventions to pregnant smokers at
the first prenatal visit as well as throughout the course of
pregnancy.”
Martin JA et al. Births: Final data for 2002. National vital statistics reports. Vol 52 no 10. National Center for Health Statistics. 2003
Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008
Smoking during pregnancy, 2005-2009
Number of women
Percent
70, 529
12
Bladen County
341
16
Nash County
759
12
Onslow County
1,821
11
Rockingham County
1,109
21
Wayne County
1,097
12
North Carolina
NC State Center for Health Statistics, NC Residents 2005-2009 # and % of births to mothers that reported smoking prenatally
What providers can do
 Move beyond screening
and recommendations
 Provide brief smoking
cessation counseling and
use pregnancy-specific selfhelp materials
 Use the 5 A’s regularly with
preconception, pregnant
and post-partum patients
 Connect patients with
support such as the NC
Quitline
Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008
Women & weight in North Carolina
 58% of women in NC of childbearing age (18-44) are
overweight or obese
 43% of young women ages 18-24 are overweight or obese
 There is also a racial disparity in weight status for women
18 years and older
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56% of white women are overweight or obese
73% of African-American women are overweight or obese
56% of other minorities are overweight or obese
NC Behavioral Risk Factor Surveillance System, 2010
Consequences
 U.S. society focuses on external consequences of overweight
and obesity, i.e. how we look
 As health professionals it can be helpful to re-frame
discussions toward medical/physical consequences of
overweight and obesity
 For women of childbearing age the consequences of
overweight & obesity span two generations
 Risk of consequences increases progressively as BMI
increases
Kellner, S. Maternal weight: An opportunity to impact infant mortality in North Carolina. 2010
Pregnancy risks
 Increased pre-pregnancy BMI is associated with increased
risk of:
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Preeclampsia
Gestational hypertension
Gestational diabetes
C-section
Induction of labor
Postpartum hemorrhage
Lactation failure
Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010
And for the baby…..
 Macrosomia
 Preterm delivery
 Poor APGAR scores
 NICU admission
 Shoulder dystocia
 Late fetal death
 NTDs (anencephaly and spina bifida)
Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010
The cycle repeats
 The likelihood that
overweight children will
become obese adults is
almost 9 times higher
than the risk for children
who are not overweight
 Early prenatal care
allows for counseling
about appropriate weight
gain during pregnancy to
slow or stop this cycle
Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010
Recommended pregnancy weight guidelines
 Gestational weight gain counseling should be tailored to the
woman’s pre-pregnancy BMI
 Women who gain within guidelines consistently have better
birth outcomes than those who gain more or less than the
Institute of Medicine guidelines
 Medicaid covers medical nutrition therapy (nutritional
counseling provided by a registered dietician) for pregnant
women who are overweight, obese or underweight
Weight gain during pregnancy: Reexamining the Guidelines. Institute of Medicine, 2009
Recommended pregnancy weight guidelines
Weight gain during pregnancy: Reexamining the Guidelines. Institute of Medicine, 2009
Early prenatal care counseling
 When does your practice give patients information about
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
risk behaviors (alcohol, smoking, cat litter, etc.),
medication use, healthy weight and preventive measures to
ensure a healthy pregnancy and birth outcome?
Do all women receive this information in a way that can be
tracked?
Who provides this information?
What method of information sharing is used?
Who in the community does a good job of getting this
information to women in effective ways?
Case study
 Maya is a 17-year-old
young woman who found
out she was pregnant
after missing two
periods. She was very
confused about what she
should do and kept living
her life as normally as
possible. She visited the
health department at
around 20 weeks to see if
she could find out if the
baby was a girl or a boy.
Case study
 Sarah is a 15 year old
young woman who kept
her pregnancy hidden for
the first trimester. Her
parents took her to their
private practice
physician after they
discovered her
pregnancy at around 22
weeks.
Prenatal care & transition to medical home
Opportunistic
preconception
health care
Transition to
medical home
Healthy
outcomes
Improved
preconception
health
Early
prenatal
care
Maternal & child health best practices
 Early entry and effective utilization of prenatal care
 Establishment and utilization of a medical home




(for non-pregnant women)
Reproductive life planning
Tobacco cessation counseling using the 5 A’s approach
Promotion of healthy weight
Domestic violence prevention
Principles of a medical home
 Personal physician: Each patient has an ongoing
relationship with a personal physician trained to provide
first contact, continuous and comprehensive care
 Physician directed medical practice: The personal
physician leads a team of individuals at the practice level
who collectively take responsibility for the ongoing care of
patients
 Whole person orientation: The personal physician is
responsible for providing for all the patient’s health care
needs or taking responsibility for appropriately arranging
care with other qualified professionals
Joint principles of the patient-centered medical home. 2007. American Academy of Family Physicians,
American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association
Principles, cont.
 Care is coordinated and/or integrated across
specialists, hospitals, home health agencies, etc.
 Quality and safety are assured by a care planning
process, evidence-based medicine, clinical decision-support
tools, performance measurement, active participation of
patients in decision-making, and other factors.
 Enhanced access to care is available (e.g., via "open
scheduling, expanded hours and new options for
communication").
 Payment must appropriately recognize the added value
provided to patients who have a patient-centered medical
home
Joint principles of the patient-centered medical home. 2007. American Academy of Family Physicians,
American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association
What can medical homes provide
for healthy, non-pregnant women?
 A place for regular check-ups
 A place women can call if they’re not feeling well to help
them decide if they need: a clinic appointment, an
emergency department visit, a referral to a specialist, or no
visit at all
 A place that coordinates referrals for women; helps assess
if further treatment or testing is needed
 A place that can provide preconception or interconception
health counseling about relevant topics: healthy weight,
substance use, tobacco use, screenings for mental health
issues, sexually transmitted infections, etc.
What can medical homes provide for nonpregnant women with chronic conditions?
 All the services on the previous slide, plus:
 A place for regularly scheduled check-ups, lab work,
prescriptions and sometimes medications/supplies
 A place to receive specialized counseling related to their
condition (such as nutrition counseling for diabetes)
 A place that coordinates referrals for services such as
annual eye exams (for women with diabetes)
 A place with a provider who can receive and read referral
results and makes a plan of care based on those results
Transition from pregnancy to primary care
provider/medical home
 The postpartum visit is an important opportunity to




establish a medical home for young women and provide
preconception guidance for future pregnancies
Considered the “gateway to well-woman care”
Opportunity to revisit health concerns that came up in
prenatal visits and throughout the pregnancy
May be the only clinical visit for a woman between
pregnancies
Sometimes a lost opportunity

Nationally, only 59% of Medicaid patients and 80% of privately
insured patients receive a postpartum visit
The State of Health Quality, National Committee for Quality Assurance, 2007
The Postpartum visit: An overlooked opportunity for prevention, Verbiest, SB, 2009
Barriers to postpartum visit compliance
 A survey of local public health nurses in North Carolina
showed several barriers to access of postpartum care in
local health departments:
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

Lack of transportation, lack of childcare, children not being welcome
at the postpartum appointment, women not realizing the importance
of this visit
Financial issues such as an outstanding prenatal care bill or the loss
of Medicaid coverage
Inconvenient hours and poor customer service (long waits during
appointments and difficulty getting through on the phone to
schedule appointment)
Long Valentin, A. "Postpartum Visit Utilization Assessment: North Carolina Local Public Health Departments," North Carolina Division of Public Health, Women's
Health Branch, 2008
Postpartum visit components
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
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
Basic physical exam
including pelvic exam and
incision exam (if applicable)
Glucose testing for women
who had gestational diabetes
Postpartum depression &
domestic violence screenings
Breastfeeding support
Reproductive life planning
counseling, focus on
pregnancy spacing
Contraception if desired
Active assistance in helping
patient transition to a
“medical home”


Immunizations like varicella
and MMR
Smoking cessation counseling,
as up to 70% of women who quit
during pregnancy start smoking
again within a year after
delivery
Birth spacing recommendations
 Recommended birth
spacing in the U.S. is at
least 18 months between
prior delivery and next
conception (and no more
than five years)
 42% of North Carolina
women had less than an
18 month interval in
2008


Under age 20, 73%
Age 20-24, 54%
Zhu BP. Effect of interpregnancy interval on birth outcomes: findings from three recent US studies. International Journal of Gynecology and Obstetrics (2005) 89, S25—S33
North Carolina State Center for Health Statistics, 2008.
Transition to a medical home
 In addition to the postpartum visit, discuss medical home
at:





Prenatal visits during the last month of pregnancy
Hospital discharge
Home visits
Newborn pediatric visits
WIC appointments
The Postpartum visit: An overlooked opportunity for prevention, Verbiest, SB, 2009
Transition to medical home
 Do women who have recently (or maybe not so recently)
had a baby consider their OB/GYN or midwife their
primary health care provider?
 Is this an ideal arrangement?
 If not, how would you suggest starting a conversation with a
young mother about where her new medical home could
be?
 Are pediatricians involved in recommending medical
homes? Could they be?
Points of entry into medical homes/primary
care providers
 What are the medical homes for non-pregnant young
women in this community?
 How and when do young women access these medical
homes?
 What are the entry points by which they may reach these
medical homes?
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Postpartum visits
Pregnancy planning visits
Annual exams
Sick care
Referral from health department family planning clinics
Referral from negative pregnancy tests
Other?
Medical homes in this community
 Who are safety net providers that serve as medical homes?
 Is there a referral network in place throughout the
community to make sure all women who want a medical
home can access one?
 Resources
(Also found in Section 3 of the Circle of Care for Women Training Materials &
Toolkit binder):
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Nchealthcarehelp.org
Nccarelink.gov
Ncfreeclinics.org
Step by step to a medical home
1.
2.
3.
4.
5.
Remind patients that medical homes help them stay healthy
and prevent emergency room visits
Provide specific local medical home options, reminding young
patients that the best medical home for their needs may change
over time
Write out the steps of how to connect with a medical home
Be specific: practice names, phone numbers and guidance
about when to call the medical home
Some practices follow up by phone as part of routine
postpartum care, ensuring the patient has connected with the
medical home
Case study
 Kristina had a baby boy 6
weeks ago. She is 18
years old and her
Medicaid benefits are
about to expire. She had
genital herpes and was
treated during the
pregnancy. She also has a
history of depression and
asthma. She asks for
some extra depression
and asthma medications
at her postpartum visit.
Case study
 You see a 19 year old
mother at a (pediatric)
baby well check and she
asks you about prescribing
her the patch as she wants
to stop smoking for the
baby. After some basic
questions you learn that
she no longer has any
health insurance and lists
her OB/GYN at the local
community health center
as her primary physician.
The circle of care for women
Opportunistic
preconception
health care
Transition to
medical home
Healthy
outcomes
Improved
preconception
health
Early
prenatal
care