Preterm and Perinatal Health

The DMCN Preterm and Perinatal Health module is utilized by program owners aiming to enhance maternal and infant outcomes, with objectives including:

• Reducing preterm births
• Decreasing occurrences of neonatal intensive care unit (NICU) admissions
• Shortening NICU stays
• Promoting excellent maternal and infant health practices
• Lowering overall costs during the perinatal stage of maternal and infant life

Program owners have the flexibility to utilize existing care networks or engage various providers and organizations within a specific region or network of health and social care teams sharing common goals.

Program owners leveraging the Preterm and Perinatal Health module can tailor parameters for the care management network. For instance, teams may conduct in-person and/or virtual risk assessments for eligible patient-centered case management. Sample risk stratifications include maternal age, multiple gestation, current preterm labor, vaginal bleeding > 14 weeks, barriers to adequate prenatal care, or a history of preterm births, low birth weights, or perinatal death.

Similar to other DMCN modules, the Preterm and Perinatal Health module facilitates coordination across multiple care networks to ensure mothers and infants receive appropriate care and prevent duplication of efforts for at-risk conditions. Typical care coordination involves referrals and treatment updates among obstetrics and primary care providers.

An integral aspect of any care coordination program is the ability to measure outcomes and assess effectiveness to adjust care plans promptly. To complement data collected from care teams, DMCN can analyze data from Medicaid claims or other available electronic records interfaces, including real-time Health Level 7 (HL7) data feeds, as well as birth data for monitoring effectiveness.

The DMCN Preterm and Perinatal Health module was effectively utilized by the South Carolina Partners for Preterm Birth Prevention program, a public/private partnership among providers of Medicaid perinatal enrollees in the Lowcountry Region of South Carolina. Outcomes from this program included:

• Reduction in deliveries < 32 weeks
• Decrease in Very Low Birth Weight (VLBW) deliveries
• Decrease in frequency of VLBW
• Decrease in mean duration of NICU admission

For further details on the program components and actual outcomes, please contact DDIMTG.

The DMCN Asthma Registry module is utilized by healthcare teams aiming to enhance the quality of life for asthma patients and their families while mitigating asthma-related emergency department visits and hospitalizations.

Proactive Approach: DMCN serves as a patient registry, offering automated risk stratification based on rules set by the healthcare team. Each patient undergoes automatic nightly assessment to ensure precise stratification.

Reactive Measures: DMCN generates alerts to the healthcare team when a patient experiences an event leading to an emergency department visit. This push technology ensures timely notification, enabling immediate adjustment of the patient's care plan to prevent reoccurrence. Local school health nurses are crucial in the community care network for pediatric patients enrolled in area schools.

The DMCN Asthma Registry module was effectively employed by the Greenville (S.C.) Health System Children’s Hospital Center for Pediatric Medicine Asthma Action Team, resulting in a substantial reduction in emergency department visits among pediatric asthma patients. Emergency Department (ED) visits decreased from 855 visits/year per 1,000 patients to 267 visits/year per 1,000 patients.

For further details on the program’s outcomes and recognition as an American Hospital Association (AHA) NOVA awardee, refer to page 3 in the following publication: AHA NOVA Awardee Publication and contact DDIMTG.

The DMCN Elderly Care Coordination module is used by program owners to improve quality of care for at-risk elderly patients. Also known as the Aging Q3module, it originated as a care coordination tool for the Medical University of South Carolina (MUSC) program of the same name. The Aging Q3program aims to enhance:

1. Quality of Education among the faculty of physicians caring for geriatric patients
2. Quality of Care for geriatric patients provided by physicians at the point of care
3. Quality of Life for geriatric patients by addressing the specific needs for elderly patients, often at-risk for health complications, including falls and other health risks associated with the elderly (pneumonia, dementia, COPD, CHF, depression, diabetes, etc.)

In addition to the Elderly Care Coordination module in DMCN, the Aging Q3 program uses these additional features:

• Data feeds from the hospital emergency department (ED) to alert care givers via secure email in the event of patient events or admissions.  
• Cluster Risk Stratification based on International Classification of Diseases (ICD) codes and algorithms used by the program owners to classify patients as healthy, medium risk, high risk. DMCN displays the classification as a color code for the patient, for ease of recognition.
• Utilization Risk Stratification based on ED visits and algorithms used by program owners to classify patient hospital and ED utilization from minimal to high. DMCN presents the classification in a color-coded format for easy identification.

 For further details on the program components and actual outcomes, please contact DDIMTG. 

 The DMCN Patient-Centered Medical Home module is used by program owners to enhance the quality of care, efficiency, effectiveness, and cost reduction within the patient population of the medical home. Using DMCN, the PCMH improves comprehensive primary care for patients and coordinates their healthcare needs with associated specialists. 

The DMCN PCMH module originated as a care coordination tool for the first PCMH for the Medical University of South Carolina (MUSC). DMCN plays a crucial role in the success of an integrated outcomes PCMH by providing:

• Communication among healthcare specialists
• Alert notifications for admissions, discharges, Emergency Department (ED) visits, and clinical visits, enabling primary care teams to follow up with patients promptly
• Tracking of Treatment plans for chronic diseases, including asthma, diabetes, COPD, and CHF
• Timely Follow-up with Patients after Discharge resulting in higher reimbursement rates 

In addition to the care coordination and treatment plan features, the DMCN PCMH program includes the following components:

• Data feeds from the hospital emergency department (ED) to alert care givers via secure email in the event of patient events or admissions.  
• Cluster Risk Stratification based on International Classification of Diseases (ICD) codes and algorithms used by the program owners to classify patients as healthy, medium risk, high risk. DMCN displays the classification as a color code for the patient, for ease of recognition.
• Utilization Risk Stratification based on ED visits and algorithms used by program owners to classify patient hospital and ED utilization from minimal to high. DMCN presents the classification in a color-coded format for easy identification.

For further details on the PCMH program components and integrations for patient providers, please contact DDIMTG.

The DMCN Referral Care Coordination module facilitates case managers in tracking referrals across various health and social agencies to ensure prompt assignment, receipt, and follow-up. Through DMCN, Referral Care Coordinators promptly identify resource constraints within the network agencies, ensuring clients receive optimal care.

Initially designed as a coordination tool for the United Way of Greater Greensboro (UWGG) Family Success Center, DMCN significantly contributes to successful client outcomes by enabling:  

• Bi-Direction Communication among case managers from different agencies
• Tracking of Consent and Referral Forms
• Verification of Referral Assignment and Receipt

In addition to care communication and management features, the DMCN Referral Care Coordination program includes the following components:

• Flexible configuration options for referral types and distinguishing mandatory vs. non-mandatory client consent.
• Various notification methods for referral events, including email and SMS text messages.
• Application Program Interface (API) options for seamless integration with existing systems.
• Updates on critical Information, facilitating the communication of vital details such as resource unavailability or waiting list status among agencies.

For further details on the  Referral Care Coordination  program components and integrations for patient providers, please contact DDIMTG.