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Postpartum Visits
CMS Post-Partum Measure: https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_336_MIPSCQM.pdf
DENOMINATOR: All patients, regardless of age, who gave birth during a 12-month period seen for postpartum care visit before or at 8 weeks of giving birth
Denominator Criteria (Eligible Cases): All patients, regardless of age AND Patient procedure during performance period (CPT): 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622 AND Postpartum care visit before or at 8 weeks post-delivery
NUMERATOR: Patients receiving the following at a postpartum visit:
• Breast-feeding evaluation and education, including patient-reported breast-feeding
• Postpartum depression screening
• Postpartum glucose screening for gestational diabetes patients
• Family and contraceptive planning counseling
• Tobacco use screening and cessation education
• Healthy lifestyle behavioral advice
• Immunization review and update
For PP Visit definitions: Refer to existing Data Dictionary
Consider methods to look for all visits not just PP coding
Contraceptive counseling and provision
Refer to existing Data Dictionary
Previous Resources
Diabetes screening for women with GDM-affected pregnancies
Refer to existing Data Dictionary
Previous Resources
Postpartum depression and anxiety screening, referral, and treatment
ACOG guideline: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
HEDIS measure: https://www.ncqa.org/hedis/measures/postpartum-depression-screening-and-follow-up/
The percentage of deliveries in which members were screened for clinical depression during the postpartum period, and if screened positive, received follow-up care. Two rates are reported.
Depression Screening: The percentage of deliveries in which members were screened for clinical depression using a standardized instrument during the postpartum period.
Follow-Up on Positive Screen: The percentage of deliveries in which members received follow-up care within 30 days of a positive depression screen finding.
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“Appropriate screening at the comprehensive post-partum visit”
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Validated tools for screening?
Edinburgh? (EDPS)-- short vs long
Other validated tools?
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Patients with prior screening in pregnancy?
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High risk patients/SMI
SMI diagnosis codes?
Mood disorder diagnosis codes?
Prior history of PPMD
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Addressing PP anxiety/psychosis?
Emergent treatment: active SI, psychosis
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https://www.samhsa.gov/find-help/national-helpline
Cardiovascular care (hypertensive disorders of pregnancy)
Hypertension:
NICE Guidelines 2019: https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and-management-pdf-66141717671365
Diagnosis and management of hypertension in pregnancy: summary of updated NICE guidance https://www.bmj.com/content/366/bmj.l5119
CMQCC: Hypertensive disorders of pregnancy toolkit https://www.cmqcc.org/resources-tool-kits/toolkits/HDP
Hypertensive disorders of pregnancy
Chronic hypertension—Hypertension that is present at the booking visit or before 20 weeks’ gestation, or if the woman is already taking antihypertensive medication when starting maternity care. It can be primary or secondary in aetiology
Gestational hypertension—New hypertension presenting after 20 weeks of pregnancy without significant proteinuria
Pre-eclampsia—New onset hypertension (>140 mm Hg systolic or >90 mm Hg diastolic) after 20 weeks of pregnancy and the coexistence of one or both of the following new-onset conditions:
Proteinuria (urine protein:creatinine ratio ≥30 mg/mmol, or albumin:creatinine ratio ≥8 mg/mmol, or ≥1 g/L [2+] on dipstick testing)
Other maternal organ dysfunction, including features such as renal or liver involvement, neurological or haematological complications, or uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth)
Postpartum HTN Management: (NICE 1.9):
1.9.3 As antihypertensive agents have the potential to transfer into breast milk: • consider monitoring the blood pressure of babies, especially those born preterm, who have symptoms of low blood pressure for the first few weeks • when discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding. [2019]
1.9.4 Offer enalapril[5] to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium. [2019]
1.9.5 For women of black African or Caribbean family origin with hypertension during the postnatal period, consider antihypertensive treatment with: • nifedipine[3] or • amlodipine if the woman has previously used this to successfully control her blood pressure. [2019]
1.9.6 For women with hypertension in the postnatal period, if blood pressure is not controlled with a single medicine, consider a combination of nifedipine[3] (or amlodipine) and enalapril[5] . If this combination is not tolerated or is ineffective, consider either: • adding atenolol or labetalol to the combination treatment or • swapping 1 of the medicines already being used for atenolol or labetalol. [2019]
1.9.7 When treating women with antihypertensive medication during the postnatal period, use medicines that are taken once daily when possible. [2019]
1.9.8 Where possible, avoid using diuretics or angiotensin receptor blockers[5] to treat hypertension in women in the postnatal period who are breastfeeding or expressing milk. [2010, amended 2019]
1.9.9 Treat women with hypertension in the postnatal period who are not breastfeeding and who are not planning to breastfeed in line with the NICE guideline on hypertension in adults. [2019]
Cardiovascular Disease in Pregnancy/Postpartum:
Substance use disorder screening, referral, and treatment:
WHO Guidelines: https://www.who.int/publications/i/item/9789241548731
Evidence Profile 1: Screening and brief interventions
Evidence Profile 2: Psychosocial interventions for harmful use and dependence on alcohol and other substances in pregnancy
Evidence Profile 3: Detoxification or quitting programmes for alcohol and other substance dependence in pregnancy
Evidence Profile 4: Pharmacological treatment (maintenance and relapse prevention) for alcohol and other substance dependence in pregnancy
Evidence Profile 5: Breastfeeding
Evidence Profile 6: Management of infants exposed to alcohol and other psychoactive substances
SAMHSA Opiate Treatment in Pregnancy: https://store.samhsa.gov/sites/default/files/d7/priv/sma18-5054.pdf
Other supporting evidence-based recommendations for postpartum care services:
Breastfeeding Support:
CDC Guide to Strategies Supporting Breastfeeding: https://www.cdc.gov/breastfeeding/pdf/bf-guide-508.pdf
CMS Exclusive Breastfeeding: https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2579
Comments:
Michele Whitt (Unlicensed) Many local and state and national programs expect support for breastfeeding (WIC, etc)
Epic has a navigator section that might be usable for directing users to breastfeeding support
Elements for breastfeeding can come from the eCQM
Consider offering or tracking lactation services/consults
May be difficult in EHR platforms because of 1) data capture and variability 2) ref
Tobacco use screening and cessation education:
Include tobacco screening?
Follow up recommendations/therapy?
Healthy lifestyle behavioral advice
Need to define?
Immunization review and update
HEDIS Prenatal immunization quality measure: https://www.ncqa.org/hedis/measures/prenatal-immunization-status/
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Updated Measures will be located here when completed. Draft version is available here.
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