CARE COORDINATION

A referral to the enhanced care coordination system opens the door to resources that may make all the difference in the lives of a growing family.

As mentioned earlier, receiving care coordination in Baltimore City has also led to an 80% decreased risk of experiencing fetal or infant death.

In addition, these vital supports don’t cost your patients anything, as many care coordination services are connected to health insurance or public health grants.

Clients connect to the enhanced care coordination system through three channels. (And, it’s important to note that there is no wrong door to access the system!)

• Self-referrals are possible through a straightforward website form that collects vital information to start the coordination process.

• Community organizations, such as a safe sleep ambassador or behavioral health provider, can refer clients.

• Health care providers — YOU — can refer patients.

Because health care providers are such trusted sources of information for patients, this last channel is incredibly important, representing more than half of all care-coordination referrals in recent years.

In addition, a relatively new state law, the Maryland Maternal Health Act, requires local health departments and certain health care providers and hospitals to complete these forms.

Providers, who make over half of all referrals to care coordination in Baltimore City, use two main channels to connect patients to the centralized system.

The Prenatal Risk Assessment (PRA) should be filled out by providers or clinic staff during a patient’s first prenatal care visit. (Maryland regulations require this to happen for all pregnant Medicaid participants.) This tool helps identify individuals and families at risk, connect them with vital support services, and help collect the data needed to understand the needs of local communities. It’s important to note: PRAs can be submitted any time during a pregnancy, whether the form was missed on the first prenatal visit or risk factors have changed.

• Read more about the PRA.

The Postpartum Infant and Maternal Referral (PIMR) helps Maryland hospitals refer high-risk infants and mothers — at discharge — to their local health department for care coordination. This is necessary, even if a patient had a PRA, as a family’s needs may change across the course of a pregnancy. Any circumstances that present a risk for the mother or infant can prompt a need for the PIMR, including very low birthweight, previous infant death, no prenatal care, teen motherhood, intimate partner violence, and more.

• Read more about the PIMR.

• Directions on filling out the form are also available at this MDH website.

Most providers in Maryland can now submit the forms online as part of a patient’s electronic medical record — which is a far easier process! (When that’s not possible, both forms should be faxed to the health department of the patient’s home county; contact information for every Maryland county is listed at the end of each form.) For Baltimore City residents, HCAM receives the forms and starts the care coordination process.

B’more Beginnings is how Baltimore City talks to families about our uniquely robust system of care coordination.

This focused effort, developed in collaboration with local families and providers, helps make the complexities of care coordination a little more accessible and relatable.

If your patients have questions, please direct them to the B’more Beginnings site, which includes descriptions, testimonials, and a short FAQ.

No. But, if they live in Maryland, you can still use the PRA and PIMR forms to refer them to the right place for coordinated care!

Each form includes contact information for every county in Maryland. By submitting these forms to the right place, you will help connect your patients to the wide range of services that may be available to them. Also, if a client is accidentally referred to the wrong jurisdiction, they’ll be re-routed to the correct county to connect with available resources.