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

Maternal status day of discharge

• 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

Components of the Standardized Discharge Summary

• Name and age
• Support person contact information
• Place of birth
• Gravida/para status
• Date and type of birth, gestational age at birth, relevant conditions, and complications
• Date of admission, date of discharge
• Name, contact information and appointments for relevant providers, including OB/GYN specialists, mental health provider, etc.
• Positive screening for medical risk factors, mental health, and substance use
• Medications and supplements
• Unmet actual and potential social health needs
• Suggested community services and supports
• Need for specific postpartum testing, such as glucose testing or CBC

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 (increased pain, redness, drainage, or pus)
• 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
• Foul smelling bleeding or discharge from the vagina or incision
• Severe nausea and vomiting

Postpartum visits (low risk)

• First postpartum contact between 2-5 days after discharge. Provide a home or virtual visit (phone and/or telehealth).
• Postpartum care visit for 3 weeks post discharge with provider.
• Schedule Postpartum to Primary Care Transition visit for patients with chronic conditions in 4-12 weeks post discharge.
• Schedule specialty care visit as needed prior to discharge.
• Discuss the importance of postpartum care and potential barriers.
• Consider home visitation or telehealth before the first visit regardless of income, age, or location of residence.

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

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

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

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

Education for nurses on mental health disorders

Maternal Mental Health Disorders

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

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.

Maternal status on day of discharge

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

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

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 7 days with a cardiologist prior to discharge.

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.

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

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

TCS is provided to all Medi‑Cal members any time they move from one place or level of care to another. When a member is admitted, discharged or transferred, the MCP determines what level of support is needed and works with the care team to review the discharge plan, arrange timely follow-up, and help the member get connected to care.

For pregnant and postpartum members, TCS is provided for any transition of care during pregnancy and through 12 months postpartum. Transitional care events include both hospital discharge events and the end of pregnancy, regardless of how, or where, that pregnancy ends. The completion of the TCS Birthing Supports Checklist is required for every pregnant and postpartum member. 

TCS Birthing Supports Checklist

The TCS Birthing Supports Checklist helps make sure every pregnant or postpartum member gets connected to the medical, behavioral health, and whole-person supports they need. The MCP’s care team will help arrange referrals and/or warm hand-offs based on the member’s needs and preferences:

• Medical Supports

  • Perinatal/postpartum visits according to the American College of Obstetricians and Gynecologists (ACOG)/United States Preventive Services Task Force (USPSTF) guidelines

    • Validated behavioral health screenings

    • Intimate partner violence (IPV) screening using evidence-based tool

    • Reproductive life planning

  • Pediatric visits according to the American Academy of Pediatrics (AAP) Bright Futures schedule through two-month well-child visit

  • Other follow-up visits recommended by a provider or included in the discharge summary/instructions

  • Primary care provider visit scheduled (if no visit scheduled within the past one year)

• Whole-Person Needs
  • Food, Nutrition Education, and Breastfeeding Supports
    • Women, Infants, and Children (WIC)
    • CalFresh
    • Lactation services
  • Managed Care Plan (MCP) Benefits
    • Transportation services
    • Doula services
    • Appointment assistance
    • Breast pumps
    • Enhanced care management (ECM)**
    • Community supports**
    • Community Health Worker (CHW) services 
  • Family Support Services
    • Paid Family Leave (PFL)
    • Home visiting^
    • Parenting resources§
  • Infant Support
    • Health insurance for infants
    • WIC (including infant formula)
• Behavioral Health Needs (This includes access to culturally and linguistically aligned services and supports, consistent with Medi-Cal policy.)

  • Behavioral health supports (e.g., Non-Specialty Mental Health Services (NSMHS), Specialty Mental Health Services (SMHS), Drug Medi-Cal Organized Delivery System (DMC-ODS), Drug Medi-Cal (DMC))

  • Dyadic services

**DHCS’ Closed Loop Referral (CLR) policy requires MCPs to close the loop for Enhanced Care Management (ECM) and Community Supports services.

^Home visiting services include (but are not limited to) California Department of Public Health (CDPH) California Home Visiting Program (CHVP), California Department of Social Services (CDSS) California Work Opportunity and Responsibility to Kids Home Visiting Program (CalWORKs HVP), American Indian Maternal Support Services (AIMSS), and county First 5s, as eligible.

§Parenting resources include (but are not limited to) Home Visiting services, MCP educational information, First 5, and Black Infant Health.

Hospital's Role

1. Notify the MCP of any admission, discharge, or transfer for a managed care Medi-Cal member so that the MCP can initiate TCS. Admissions/discharges/transfers refer to both delivery and non-delivery events. MCPs are required to have a dedicated TCS call-line, so work with the MCPs in your geographical area to understand workflows.
2. The member’s MCP should provide the member’s point of contact information for inclusion in the discharge packet. Encourage the member to reach out to their plan for help with follow‑up care and services.
3. Notify the MCP when a pregnant member is identified, so the MCP can initiate TCS. 
4. Hospitals can help link members to services on the TCS Birthing Supports Checklist, such as lactation support, home visiting, breast pumps, Paid Family Leave (PFL) forms, infant Medi-Cal enrollment through Newborn Gateway, coordination of follow-up appointments, and social needs screenings. Hospitals should coordinate with MCPs or the primary maternity clinic to ensure members are connected to needed supports.