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Care Management for High Risk Pregnancy (CMHRP)

Action Plan

What We Will Do:

The Division of Community Health Services of the Guilford County Department of Health and Human Services will provide free case management to pregnant women enrolled in NC Medicaid and a limited number of low-income insured women through the Care Management for High Risk Pregnancy (CMHRP) program. 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. Care management is provided by registered nurses or social workers.

Who Is Involved:

GCDHHS, Public Health Division

Cone Health Family Medicine Center 

Cone Health and Wake Forest High Point Medical Center 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:

Center for Women’s Health Care - Elam, Greensboro, Stoney Creek, High Point and Renaissance, Greensboro OB/GNY, 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, Wake Forest Health Network OB/GYN -Elm, Pinewest OB/GYN, and Eagle OB/GYN

When this Takes Place:

Service begin upon identification from the referral source to 6 weeks post-delivery. 

 How We Will Do it:

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 < 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. Specially trained nurses and social workers assess and provide follow up to patients via phone contacts, office visits, home visits and telehealth weekly to montly based on need. 

Measures

Time
Period
Current Actual Value
Current Target Value
Current
Trend
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% Change

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Scorecard Container Measure Action Actual Value Target Value Tag S A m/d/yy m/d/yyyy