Provider Resources for Postpartum Discharge by Topic

Resources for assessing, educating, and referring patients and families to provide quality care and improve outcomes.

Health-Related Social Needs (Social Determinants of Health) Assessment

Recommendation

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

 

Components

Social determinants of health:

  • Housing insecurity
  • Food insecurity
  • Access to transportation
  • Difficulty paying for prescriptions or medical bills
  • Family relationships
  • Education and literacy
  • Employment and work

 

Examples of Tools

TJC, National Patient Safety Goal – Improve health care equity NPSG.16.01.01

ACOG, Sample Screening Tool

Maven, Social Determinants of Health Short Screener

AAFP, Social Needs Screening Tool

CMS, Screening Tool Core Questions

National Association of Community Health Centers, PRAPARE® Screening Tool (license agreement required)

 

Health Related Social Needs (Social Determinants of Health) Follow-Up

Recommendation

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

 

Components

Enter maternal geographic-specific information into the Find Help website for free or reduced-cost resources like food, housing, financial assistance, healthcare and more. Additional mechanisms to assess health needs and provide support after discharge include:

  • Home visits (including Home Health, Public Health Nursing)
  • Phone calls
    • Postpartum nurses
    • Perinatal nurse navigator
  • App-based support
  • Community organizations
    • CHW/Promotora
  • Postpartum doulas

 

Examples of Tools

Find Help    

Blue Shield of California, Maven Maternity, Reproductive, and Family Health Programs

DHCS Doula Directory

Black Infant Health Programs

Adolescent Family Life Program

Cal-Learn

National Association of Community Health Centers, PRAPARE® Screening Tool (license agreement required)

At or High-Risk Population

At or High-Risk Population Assessment

Recommendation

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.

 

Components

At-Risk Patients

Risk factors

  • Medical
    • Hypertension
    • Heart disease
    • History of DVT or embolism
    • Sepsis
    • Hemorrhage
    • BMI <18 or >30
    • Maternal age <16 or >35
    • C-section/laceration (3rd/4th)
    • Substance use disorder
    • Smoking/alcohol
  • Social
    • Safety concerns
    • Food/housing insecurities
    • Lack of transportation
    • Adverse childhood/birthing experiences
    • Intimate partner violence
  • Mental health
    • Depression
    • Anxiety
    • Other mental health disorders

High-Risk Patients

Maternal status 

  • Normal vital signs
  • Uterine involution and lochia are normal
  • Absence of signs and symptoms of wound or incisional infection
  • Urinary output appropriate
  • Ambulates without difficulty
  • Pain adequately controlled
  • Ability to void and pass gas
  • Ability to take fluids and food without difficulty

 

Examples of Tools

At-Risk Patients

Perinatal Mental Health Tools

High-Risk Patients

At or High-Risk Population Education

Recommendation

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)

 

Components

Postpartum warning signs:

  • Chest pain or fast heartbeat
  • Trouble breathing
  • Thoughts of harming yourself or baby
  • Bleeding, soaking through one pad/hour or blood clots the size of an egg or bigger
  • Incision that is not healing
  • Swelling, redness, or pain in legs
  • Temperature of 100.4 degrees F or higher or 96.8 degrees F or lower
  • Headache that does not get better or bad headache with vision changes
  • Dizziness of fainting
  • Extreme swelling of hands or face
  • Severe abdominal pain
  • Severe nausea and vomiting

 

Examples of Tools

AWHONN

AIM

Other Resources

Preeclampsia Foundation

CMQCC

At or High-Risk Population Follow-Up

Recommendation

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.

 

Components

Postpartum visits (at-risk or high-risk):

  • Specialist/MFM
  • Cardiology
  • Diabetes
  • Mental health disorders

Follow up with OB or relevant specialist within 2-3 days.

For women and birthing people who have had sepsis, follow-up contact should be made within 3-4 days after discharge or sooner, depending on provider recommendations.

Schedule all patients with diagnosed cardiac disorders or at-risk for atherosclerotic cardiovascular disease (ASCVD)--preterm birth, diabetes, hypertension, preeclampsia, and eclampsia--for appointments within 7 days with a cardiologist prior to discharge.

 

Examples of Tools

A Million Hearts

CMQCC

Preeclampsia Awareness Tools

Maternal Mental Health

Maternal Mental Health Assessment

Recommendation

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

 

Components

  • Mental health
    • Depression
    • Anxiety
    • Other mental health disorders

Education for nurses on mental health disorders

 

Examples of Tools

Victoria State Department of Health, Edinburgh Postnatal Depression Scale (Multiple languages)

Orange County Health Care Agency, PHQ9

Edinburgh Postnatal Depression Scale - US (Coming soon)

Perinatal Mental Health Tools (Coming soon)

Massachusetts Child Psychiatry Access Program For Moms, Summary of Emotional Complications During Pregnancy and Postpartum

Maternal Mental Health Disorders Education

Recommendation

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.

 

Components

Maternal Mental Health Disorders

  • Depression, Anxiety, Childbirth Post-Traumatic Stress Disorder (CB-PTSD)

 

Examples of Tools

Orange County Health Care Agency (California), PMAD Treatment Pathway

Massachusetts Child Psychiatry Access Program For Moms, Summary of Emotional Complications During Pregnancy and Postpartum

National Maternal Mental Health Hotline (NMMHH), NMMHH Promotional Poster

Maternal Mental Health Now, Speak Up Brochure

ACOG, ACOG Lifeline for Moms

National Maternal Mental Health Hotline: 1-833-852-6262

Maternal Mental Health Follow-Up

Recommendation

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

 

Components

Remind new parents to add the National Maternal Mental Health Hotline to their contact list.

  • Hotline is free, confidential, and available 24/7 to help new parents and loved ones. Call or text.

 

Examples of Tools

Hypertension in Pregnancy

Hypertension in Pregnancy Assessment

Recommendation

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.

 

Components

Maternal status:

  • Blood pressure within normal range
  • Lab tests have been reviewed and within normal limits

 

Examples of Tools

CMQCC, Improving Health Care Response to Hypertensive Disorders of Pregnancy Toolkit (2021, rev. 2024) (Scroll down to Toolkit)

Hypertension in Pregnancy Education

Recommendation

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.

 

Components

Postpartum warning signs:

  • Headache that does not get better or bad headache with vision changes
  • Dizziness of fainting
  • Extreme swelling of hands or face
  • Severe abdominal pain

 

Examples of Tools

Preeclampsia Foundation

CMQCC

Hypertension in Pregnancy Follow-Up

Recommendation

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

 

Components

Follow up with OB or relevant specialist within 2-3 days.

Schedule all patients with diagnosed cardiac disorders or at-risk for atherosclerotic cardiovascular disease (ASCVD)--preterm birth, diabetes, hypertension, preeclampsia, and eclampsia--for appointments within 2-3 days with a cardiologist prior to discharge.

Consider remote BP monitoring for women and birthing people with known preeclampsia and/or elevated BP during pregnancy/labor. 

  • Provide education on BP home monitoring
  • Provide BP cuff at discharge for home monitoring
  • Provide call number for reporting of BP results
  • Provide patient with Blue Band and/or wallet card for easy provider identification of preeclampsia risk
  • Provide emergency call number for hypertensive disorders of pregnancy warning signs and symptoms
  • Instruct patient to return for BP check in ED/OB Triage or with provider no later than 7-10 days (3-5 days if severe) if unable to be monitored at home

 

Examples of Tools

Preeclampsia awareness tools

Disability/Leave

Disability/Leave Education

Recommendation

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.

 

Components

Disability/Parental Leave

The following may be eligible for paid time off, job protection, and/or work-related accommodation:

  • Postpartum birthing person
  • Spouses/fathers
  • Foster parents
  • Adopting parents
  • LGBTQ+ parents
  • Families experiencing pregnancy loss
  • NICU families
  • Lactation

 

Examples of Tools

Postpartum Disability Leave Patient Education

Taking Leave from Work

Sample letters (Search by Resource Type > Sample Letters)

Disability and Extended Disability

Accommodations for Pregnancy, Childbirth, and Lactation

Medi-Cal Services

Postpartum Services for Medi-Cal Members Follow-Up (For Medi-Cal Members)

Recommendation

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 

 

Components

Hospital’s Role

  1. Notify the Managed Care Plan (MCP) for an admission, discharge, or transfer for a managed care birthing Medi-Cal member so that the MCP can connect the member to TCS.
  2. Include the MCP-specific TCS call line phone number in the discharge paperwork for the Medi-Cal member, if available.
  3. Ask the Medi-Cal member to call their MCP directly to receive more information on TCS. TCS acts like a bridge to support the Medi-Cal member in connecting to needed services including, but not limited to, follow-up appointments and referrals, and Whole-Person Care Services.

 

Examples of Tools

Postpartum Services for Medi-Cal Members Follow-Up (For Providers)

Recommendation

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 

 

Components

All managed care 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.

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.

Hospital’s Role

  1. Notify the Managed Care Plan (MCP) for an admission, discharge, or transfer for a managed care birthing Medi-Cal member so that the MCP can connect the member to TCS.
  2. Include the MCP-specific TCS call line phone number in the discharge paperwork for the Medi-Cal member, if available.
  3. Ask the Medi-Cal member to call their MCP directly to receive more information on TCS. TCS acts like a bridge to support the Medi-Cal member in connecting to needed services including, but not limited to, follow-up appointments and referrals, and Whole-Person Care Services.

 

Examples of Tools


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