Signature Medical Group (SMG) is an independent, multi-specialty physician group guided by the principle that physicians make a lasting difference in healthcare delivery by using their knowledge and ability to do what is right for patients and the community. The Signature Strong Start Maternity Medical Home program is designed to reduce preterm births among at-risk Medicaid beneficiaries and improve pregnancy outcomes.METHODS:
The program consists of an interdisciplinary team (nurse navigator, social workers, Ob-Gyn physicians) who implement patient-centric care coordination to address the unique needs for each patient as well as conduct biopsychosocial risk assessments to identify risk factors and stressors that can negatively impact maternal and fetal health.RESULTS:
In the two years the program has been operational, total enrollment stands at 1,480 women, with 671 live births. The program's preterm birth rate is currently 7.5%, a dramatic reduction from the SMG historical average of 10.4% for this patient population. The overall impact is better health outcomes for women and infants at lower aggregate cost.CONCLUSION:
A successful model for enhancing prenatal care to improve health, patient care, and lower costs, includes four components: • Evidence-based prenatal risk stratification through an Ob-Gyn led care team • Establishment of individualized patient education by a nurse navigator based on risk and health behaviors, including increased communication between prenatal visits • Care coordination based on identified and evolving psychosocial risks and shared decision-making to create individualized care plans, including referrals to community resources • Access to childbirth education classes, nutritionists, family planning, smoking cessation, and behavioral health services.