At-Risk Patients

Screen all patients for postpartum risk factors:

• Provide linkage to community services/resources prior to discharge
• Educate on the importance of timely follow-up with their OB and/or primary care provider for ongoing coordination of care
• Women and birthing people at risk for maternal mental health disorders include those who 1) may have exhibited depressive, anxiety or other mental health symptoms but scored below the cut-off for depressive or anxiety disorder on screening tests; 2) had previous episodes of depression or anxiety; or 3) have social risk factors such as low income, intimate partner violence, or being an adolescent

Standardize mental health screening processes and methods to address a positive screen within 2-5 days of discharge.

Discuss the appropriate level of maternity care facility for reassessment needs. Patients should return to the facility with OB/ED or OB Services to ensure the availability of an obstetrician/MFM specialist.

High-Risk Patients

Assess maternal status day of discharge and discuss with the healthcare team if outside of normal range:

• Standardize nursing protocols and order sets to allow for additional lab assessments
• Automatically cancels discharge order until further assessment conducted

Include pathways in EMR that alert nurse/provider for reassessment/referral needs including hypertension, cumulative hemorrhage, sepsis, and thromboembolic disorders.

Conduct screening for Social Determinants of Health (SDoH) needs for all patients before hospital discharge.

Assess maternal status day of discharge and discuss with the health care team if outside of normal range.

• Standardize nursing protocols and order sets to allow for additional lab assessments
• Automatically cancels discharge order until further assessment conducted

Include pathways in EMR that alert nurse/provider for reassessment/referral needs for hypertension.

Women at risk for maternal mental health disorders include those who (1) may have exhibited depressive, anxiety or other mental health symptoms but scored below the cut-off for depressive or anxiety disorder on screening tests, (2) had previous episodes of depression or anxiety, or (3) have social risk factors such as low income, intimate partner violence or being an adolescent

Standardize mental health screening processes for all patients in postpartum prior to discharge and methods to address positive screen within 2-5 days of discharge

Assess maternal status on the day of discharge. If the patient's status is outside of the normal range, discuss with the healthcare team whether to take the following potential actions:

• Standardize the nursing protocols and order sets to allow for additional lab assessments;
• Automatically cancel the discharge order until further assessment is conducted.

Include pathways in the electronic medical record that alert the provider/clinician for reassessment/referral needs including: hypertension, cumulative hemorrhage, sepsis, and thromboembolic disorders.

Screen all patients for postpartum risk factors:

• Provide linkage to community services/resources prior to discharge;
• Educate on the importance of timely follow-up with their obstetric and/or primary care provider for ongoing coordination of care;
• Women at risk for maternal mental health disorders include those who 1) may have exhibited depressive, anxiety or other mental health symptoms but scored below the cut-off for depressive or anxiety disorder on screening tests; 2) had previous episodes of depression or anxiety; or 3) have social risk factors such as low income, intimate partner violence, or being an adolescent.

Standardize mental health screening processes and methods to address positive screens within two to five days of discharge.

Discuss the appropriate level of maternity care facility for reassessment needs. Patients should return to the facility with Obstetric/ED or Obstetric Services to ensure the availability of an obstetrician/maternal-fetal medicine specialist.

Clinicians should initiate the Plan of Safe Care with pregnant women and birthing people with an active substance use disorder, and with families of infants born exposed to substances, whether they require a report to Social Services or not.

• Continue the outpatient plan of care or initiate a plan of care.
• Provide education to patients and families on the use of the PLan of Safe Care and treatment options.
• Increase nursing education on substance exposure reporting requirements.

Educate all patients on normal/abnormal changes in the postpartum period using the Postpartum Discharge Handout:

• Micturition and urinary incontinence
• Bowel function
• Healing of perineal wound, pelvic floor, therapy/exercises
• Nerve changes/damage/tenderness along CS surgical incision
• Headache
• Fatigue
• Pain (Back, perineal, breast, incisional)
• Recovery and movement/OT
• Pillow splinting after surgery to relieve incisional pain
• Techniques for getting in/out of bed (rolling, pulling up legs)
• Pain management
• Perineal hygiene (peribottles, witch hazel, ice, etc.)
• Uterine tenderness and lochia
• Physical activity

Educate all patients on preventative measures for:

• Mastitis
• Constipation
• Peripartum infection
• Depression and anxiety
• Encourage patient to seek immediate attention if experiencing severe symptoms, including sleep disturbances, heightened irritability, confusion or feelings of being lost, difficulty communicating effectively, severe anxiety or agitation, rapid mood swings, obsessive thoughts about the baby, urges or impulses to harm self or baby, hallucinations, delusions, or unusual beliefs not based in reality
• Instruct patients to trust their instincts when they feel something is not right and reach out to a healthcare provider, or use emergency resources

Determine the patient’s social support circle/people, and include in education.

Standardized education for all patients, not just those with defined risk:

• Integrate educational opportunities throughout the postpartum stay – educate during shift assessment
• Provide handout separate from other information or booklets (consider QR codes, central hospital website, magnets/stickers, tear-out sheet)
• Instruct patient to recognize signs of potential complications and respond promptly
• Remember to tell all care providers about date of birth
• Encourage self-advocacy
• Include support system/family in education as much as possible

Educate patients at risk for cardiovascular disease (i.e. preterm birth, gestational diabetes or hypertension, preeclampsia/eclampsia) on the importance of ongoing follow-up due to increased risk later in life.

Download a three-page flyer of key points to cover with all patients at discharge. (PDF version or customizable Word version)

Educate all patients/family on the importance of safe, stable, and nurturing relationships between parents/baby:

• Recognize and respond to infant cues
• Implement soothing techniques
• Normal sleep/wake patterns
• Play interactions
• Baby wearing
• Skin-to-skin

Discuss a plan for birth spacing/contraception.

Assess patient’s understanding of disability rights.

Educate patient/family on disability/parental leave options to support newborn bonding/rearing, recovery plans for postpartum, and chronic and mental health conditions.

Assist patients in obtaining required approvals and documentation needed to apply for benefits.

Instruct patient to recognize signs of potential complications and respond promptly:

• Remind patient to tell all care providers about date of birth
• Encourage self-advocacy
• Include support system/family in education as much as possible

Educate patients at risk for cardiovascular disease (i.e. preterm birth, gestational diabetes or hypertension, preeclampsia/eclampsia) on the importance of ongoing follow-up due to increased risk later in life.

Educate all patients on maternal mental health disorders (include support system/family as possible).

Standardized treatment should begin before discharge for all patients with positive screen.

Utilize methods for addressing positive screens:

• Automated referral process for nurses/social workers;
• Immediate referral to a mental health clinician if screened as high-risk;
• Development of protocols to address emergency situations, like suicidality.

Patients with mood disorders should be provided education on the importance of follow-up care.

Complete the postpartum care plan and discuss with patients.

Share delivery and discharge information with the obstetrician, midwife, primary care provider, and/or specialists, including cardiology, care manager, etc.

Provide standardized education for all patients, not just those with defined risk.

• Integrate educational opportunities throughout the postpartum stay – educate during shift assessment.
• Provide handout separately from other information or booklets (consider QR codes, a central hospital website, magnets/stickers, a tear-out sheet).
• Instruct patients to recognize signs of potential complications and respond promptly.
• Remind patients to tell all care providers about the date of birth.
• Encourage self-advocacy.
• Include a support system/family in education as much as possible.

Educate patients at risk for cardiovascular disease (i.e. preterm birth, gestational diabetes or hypertension, preeclampsia/eclampsia) on the importance of ongoing follow-up, due to increased risk later in life.

Download a three-page flyer of key points to cover with all patients at discharge. (PDF version or customizable Word version)

Schedule postpartum visits prior to discharge for patients who have experienced pregnancy and/or postpartum complications such as postpartum depression, hemorrhage, hypertension/preeclampsia, cesarean or perineal wound infection, depression, lactation difficulties, or seizure disorders needing medication titration.

Educate the patient/family on disability/parental leave options to support newborn bonding/rearing, recovery plans for postpartum, and chronic and mental health conditions.

Assist patients in obtaining the required approvals and documentation needed to apply for benefits.

Utilize county/regional resources to address needs. Address ongoing health needs after birth.

Schedule postpartum visits prior to discharge for patients who have experienced hypertension/preeclampsia.

Provide postpartum mental health resources and support

Standardized treatment should begin before discharge for all patients with positive screen

Utilize methods for addressing positive screens 

• Automate referral process for nurse/social work
• Immediate referral to mental health clinician if screened high-risk

All patients should have access to maternal mental health support classes

Provide postpartum mental health resources and support.

Utilize methods for addressing positive screens:

• Automate the referral process for nurses/social workers
• Immediate referral to a mental health clinician if screened as high-risk

All patients should have access to maternal mental health support classes.

All managed care plan (MCP) birthing Medi-Cal members are eligible for Transitional Care Services (TCS). The phone number for each Medi-Cal member's assigned Medi-Cal MCP is on their plan ID card. Medi-Cal managed care plans (MCPs) are required to make available the following:

Transitional Care Services (TCS)
Transitional Care Services are designed to support Medi-Cal members transferring between settings, such as hospital discharges to home post-delivery. TCS provides general assistance with:

1. Appointments and follow-up for both birthing Medi-Cal member and infant
2. Obtaining medications and medical supplies
3. Referrals

Whole-Person Care Services

1. WIC, CalFresh, transportation, and housing resources
2. Enhanced Care Management and Community Supports
3. Doulas and community health workers
4. Lactation services
5. Home visiting
6. Paid Family Leave
7. Dyadic services
8. Postpartum depression screening
9. Family planning
10. Black Infant Health
11. American Indian Maternal Support Services (AIMSS) and Indian Health Programs 

Medi-Cal managed care plans (MCPs) are required to make available the following:

Transitional Care Services (TCS)
General assistance with:

1. Appointments and follow-up for both birthing Medi-Cal member and infant
2. Obtaining medications and medical supplies
3. Referrals

Whole-Person Care Services

1. WIC, CalFresh, transportation, and housing resources
2. Enhanced Care Management and Community Supports
3. Doulas and community health workers
4. Lactation services
5. Home visiting
6. Paid Family Leave
7. Dyadic services
8. Postpartum depression screening
9. Family planning
10. Black Infant Health
11. American Indian Maternal Support Services (AIMSS) and Indian Health Programs 

Schedule postpartum visits prior to discharge for patients who have experienced pregnancy and/or postpartum complications such as postpartum depression, hemorrhage, hypertension/preeclampsia, cesarean or perineal wound infection, depression, lactation difficulties, or seizure disorders needing medication titration.

Schedule postpartum visits prior to discharge.

Women who have experienced miscarriage, stillbirth or neonatal death must be seen by obstetric provider:

• Emotional support and bereavement counseling;
• Referral to support groups;
• Review of lab/pathology reports;
• Counseling regarding recurrent risk and future pregnancy planning/contraception.

Utilize county/regional resources to address needs.

Address ongoing health needs after birth.