Guilford County Division of Public Health’s Care Management for High Risk Pregnancy program provides free case management to pregnant women enrolled in NC Medicaid and a limited number of low-income insured women. The goal is to reduce the infant mortality rate in Guilford County and promote positive birth outcomes by assisting mothers with high-risk needs during pregnancy. Specially trained nurses and social workers assess and provide follow-up to patients via phone contacts, office visits, home visits, and telehealth weekly to monthly based on need. Service begins upon identification from the referral source to 60 days post-delivery. 

Services include:

• Care coordination
• Support of patient and/or OB provider identified needs, 
• Collaboration with the OB provider, 
• Service referrals to medical care, food and housing resources, transportation (for appointments) and other programs, like childbirth or breastfeeding education classes, Women, Infants and Children (WIC) nutrition program, and family planning. 

Eligibility criteria include: History of a preterm birth less than 37 weeks gestation; chronic illness such as diabetes, hypertension, HIV; homelessness, family violence, or substance use including smoking, alcohol and drug use during pregnancy, and a provider request of services. 

Partners

• GCDHHS, Public Health Division
• Cone Health Family Medicine Center 
• Cone Health and Atrium Health Wake Forest Baptist - High Point Medical Center Hospital Emergency Departments and Labor and Delivery Departments
• Cone Health Neonatal Intensive Care Unit
• Guilford Child Development -Nurse Family Partnership
• Get Ready Guilford Initiative

Practice offices include:  Health Department – Maternity Clinics in Greensboro and High Point,  Center for Women’s Health Care - MedCenter, Greensboro, Stoney Creek, High Point, and Drawbridge, Greensboro OB/GYN, Green Valley OB/GYN, Physicians for Women of Greensboro, Central Carolina OB/GYN, a Division of Unified Women's Health Care of NC, Moses Cone Family Practice, Dr. Henry Dorn, Atrium Health Wake Forest OB/GYN at Quaker Lane and Pinewest OB/GYN.

During 2024, CMHRP case managers successfully engaged 1, 409 high risk pregnant women. Case managers completed 3,580 face-to-face visits at the OB office or in the home. Over 5,852 patient-centered interactions were completed, including phone calls, videoconferences, texts, and emails. Care Managers met with patients face-to-face in the various OB offices within the county and surrounding area, as well as via TeleHealth videoconferencing, to deliver quality care management services to pregnant clients.  

The strain on the economy found many new mothers lacking resources to purchase personal hygiene items. Backpack Beginnings continues to support families in Guilford County by supplying food and diapers for the Food Pantries located at the Greensboro and High Point Health Department locations. CMHRP Care Managers deliver these much-needed items to families, along with linking them to sustainable community resources, as added support to families with high-risk pregnancy concerns.