North Carolina’s Medicaid both pays for maternal depression screening (MDS) as part of well-child visits, and also offers support to providers to promote effective MDS and response to positive screens. This support includes clear guidance about conducting screening and referring the parent and child to appropriate services, resources for identifying services for the parent and dyad, learning communities for providers, and data to help the provider self-monitor the delivery of MDS. In addition, North Carolina provides access to case-management for very young children whose mothers are experiencing depression. The organization responsible for Medicaid service delivery in North Carolina, Community Care of North Carolina (CCNC), has developed a suite of policies and supports that help ensure the well-being and healthy development of infants and young children who are at-risk due to maternal depression.
A comprehensive maternal depression toolkit for screening, referral, and follow-up gives providers easy access to key resources, including background on the value of maternal depression screening; guidance on screening tools, an algorithm for deciding when and how to respond to elevated scores, and information on management and treatment options, and guidance on provider-to-provider communications about results. The toolkit highlights the need for referral of the parent and child to relationship-based dyadic treatment and to a care coordination program called CC4C (discussed below). In addition, guidance stresses the need for follow-up social-emotional screening of the child, in response to a positive parent screen.
North Carolina Medicaid helps providers improve their practices related to maternal depression screening and response in several ways. In addition to the toolkit, CCNC can provide pediatricians with materials they can use to complete a course on maternal depression and receive maintenance of certification (MOC) credit. The course covers screening policies and procedures, the negative impacts of maternal depression on the infant, and referral practices for the mother and the mother-infant dyad. Another critical support provided by CCNC is feedback to providers. Each quarter, providers receive their MDS rates so that they know their performance on this indicator. The system’s quality improvement specialists also visit practices and can help providers increase their rates by encouraging their use of the toolkit and maternal depression MOC course, and providing individualized assistance.
North Carolina Medicaid pays for up to four maternal depression screenings in the child’s first year, conducted during well-child visits. Providers bill for the screenings under the child’s Medicaid.
Monitoring and Evaluation
This suite of supports for MDS has produced high rates of screening in North Carolina. In a 14-month period ending in March 2018, MDS ranged from 72 percent to 87 percent across providers. As of the first quarter of 2019, 43 percent of mothers of 6 month olds had received at least one maternal depression screen, an increase from 38 percent in the fourth quarter of 2018.
CC4C is a case-management program for children birth to five years who are experiencing risk factors for poor health outcomes and who require health and related services beyond those required by most typically developing children. Children whose mothers are experiencing maternal depression are eligible for CC4C services. Other children who can participate in CC4C include children with behavioral and mental health conditions, children in very low income households with continuous chaos, including parent substance abuse, children in foster care, and children experiencing abuse or neglect. CC4C serves close to 10 percent of Medicaid eligible children age 0 to 5 years in North Carolina.
Enrolled children receive services in a medical home. Case managers, who are nurses or social workers, conduct an assessment of family needs with The Life Skills Progression. This tool measures the adequacy of support systems, parent education and employment, health care, mental health and substance use, and access to basic needs. Results guide efforts to secure assistance for families to meet a wide range of needs to help reduce family stress and ensure that children’s health and mental health needs are met. Case managers connect with families through home-visits, phone calls, and visits with families to the pediatrician.
A CC4C workgroup meets monthly to help guide the work of the program. Members are representatives of the NC Division of Medical Assistance, Division of Public Health Early Intervention, the physician community, and local health departments.
CC4C is financed through Medicaid and Title V (Maternal and Child Health Services Block Grant Program). Each public health department receives a “per month per member” payment based on the county population of 0-5 year olds; this payment covers full-time staff of CC4C in each county.
Monitoring and evaluation
North Carolina is currently transitioning to managed care. The NC Department of Health and Human Services has developed a plan for maintaining the core activities of CC4C. During a two-year transition period, a clinical leadership team will develop quality measures for case-management that will be carried out in managed care organizations and existing entities that operate CC4C.
Special thanks to Marian Earls, Director of Pediatric Programs, Community Care of North Carolina, for providing information for and reviewing this profile