From Crisis to Coordination: Evaluating the Impact of a Case Management Perinatal Program
BY JAYME AMBROSE, DNP, RN, CCM, DAVID HEINRICH, BS, RN, CCM, AND SARAH SANDOVAL, BS
The United States identifies that maternal health is an area of crisis. It is a cornerstone of all national and state health initiatives. The United States is ranked 122 out of 186 countries for maternal mortality rate (MMR). This rate is based on the number of female deaths per 100,000 live births for any cause related to pregnancy (CIA, 2020). Other developing countries have seen a decrease in maternal deaths since COVID. The United States, however, has continued to rank far above other high-income countries in maternal deaths, especially for women of color (Commonwealth, 2024).
A significant factor affecting maternal health outcomes are socio-economic issues. Social disparities create inequality for maternal care, proper nutrition, safe housing and greater challenges in overall well-being. Lower income levels lead to decreased access to prenatal care, assistance during birth and support services. Socio-economic factors also increase risks of pregnancy and birth complications. These disparities impact not only the maternal health and well-being but also the children and families (Janaki & Prabakar, 2024).
The impact of socioeconomic inequality also has been shown to impact the birth weight of the newborn. In the United States, birth weights are found to drop consistently with income level. The factors contributing are beyond health insurance coverage; they are found in income instability, food insecurities and living in low-income housing (Martinson & Reichman, 2016).
New Mexico has the third-largest poverty rate in the country. The state of New Mexico struggles with major maternal and infant health disparities that largely impact those who receive Medicaid coverage. Eighty percent of state births receive Medicaid funding, which makes understanding this group crucial for statewide birth outcome improvements. Low-income populations and communities of color experience higher than national average maternal mortality rates and severe maternal morbidity and infant mortality rates in the state. The New Mexico Human Services Department (HSD) initiated a structural transformation within the Turquoise Care Medicaid managed care program by transferring perinatal case management duties to community-based organizations and maternity care providers. This article examines both the data and systemic problems which make a complete statewide perinatal case management program essential.
Maternal Health Challenges in New Mexico
The rate of maternal mortality in New Mexico reaches 31.2 deaths per 100,000 live births which greatly exceeds the national average rate of 17.3. Women who are older than 35 years face increased risks as they experience a maternal mortality rate of 48 deaths per 100,000 live births according to New Mexico Human Services Department data from 2024. Research from HSD shows that women who utilize Medicaid have a 4.6-fold higher risk of pregnancy-related deaths compared to those with private insurance, which indicates systemic healthcare access issues for Medicaid recipients.
The region records elevated severe maternal morbidity rates through labor and delivery complications that cause significant health consequences for women over time. New Mexico has higher instances of SMM among Medicaid-covered populations, which demonstrates an ongoing national health equity issue (MCHB, 2024).
Infant Health Indicators and Prenatal Access
The state of infant health in New Mexico demonstrates significant disparities. New Mexico has an infant mortality rate of 5.9 deaths per 1,000 live births, which exceeds the national average of 5.6 as reported by March of Dimes (2023). Low birthweight occurs at a rate of 8.8% while preterm birth occurs at 10.1%; both rates remain above the national standards. Medicaid-covered births and communities of color experience even worse health outcomes.
The availability of timely and sufficient prenatal care continues to present a critical challenge. In New Mexico, 23.3% of birthing individuals lack sufficient prenatal care, which exceeds the national average of 14.8%, according to March of Dimes 2023 data. Nearly a third of New Mexico’s counties have been identified as maternity care deserts, which intensifies challenges accessing maternal health services (March of Dimes, 2023).
Turquoise Care and the Shift Toward Delegated Case Management
New Mexico introduced Turquoise Care as a restructured Medicaid managed care program in July 2024 to deal with ongoing challenges. The assignment of perinatal case management responsibilities to maternity care providers along with community-based organizations stands as one of the most influential changes implemented by the program (HSD, 2024). The rationale is multifaceted: The program aims to enhance maternal and infant health results while ensuring care delivery aligns with cultural and geographic needs and develops local abilities for coordinating care.
The delegation strategy is informed by accumulating research that shows personalized care coordination by local providers produces better outcomes. The Nurse-Family Partnership demonstrates that case management programs produce better birth outcomes alongside reduced maternal hypertension and achieve cost savings of $5.70 for each dollar invested in high-risk populations according to Olds et al. (2010).
The Need for a Comprehensive Statewide Model
The delegation approach under Turquoise Care establishes a basic framework yet shows inconsistent application across different regions and organizations. Consistency and accountability become problematic due to the absence of standardized procedures and centralized supervision alongside unequal access opportunities. The significant share of Medicaid-covered births combined with historical health disparities in New Mexico signals the need for a complete perinatal case management program that standardizes best practices to maintain care continuity while improving community partnerships.
The program would match national standards while reflecting federal Medicaid recommendations for improved maternal care models together with care coordination and community health partnerships.
Program Description
When the enhancements of the maternal care model through Turquoise Care emerged, health plans began looking for community-based care coordination partners. Adobe Population Health (APH) was able to meet the needs of three of the four health plans and contract with them to provide the components of the state’s maternal model of care.
APH created the perinatal model as a team that is based on geographic locations or pods. Each pod consists of a case manager, an OB/GYN experienced RN, a transition of care coordinator and an engagement specialist. Each member of the team interacts with each other consistently and with the member at different periods throughout the program.
The goal of the program is to improve both mom and baby outcomes through addressing social risks, providing trimester-based education, and ensuring that perinatal and postnatal care is provided. The measurable outcomes are level of engagement, pre-term births, underweight births, NICU stays and deaths. Additional goals are attendance at provider visits, testing for STDs, ultrasounds, testing for gestational diabetes and post-partum depression screening.
The initial contact is made by the engagement team. They are reaching out via phone, text and postcard to get the moms scheduled for their initial visit with the case managers. The process also includes a drive to the patient’s home to drop off educational material APH contact information if no contact has been made.
The engagement team is also meeting with the patient’s assigned providers and the local community agencies like WIC to share information about the perinatal program and to explain the referral process into APH’s services. They are also placing flyers in local stores and laundromats with a QR code for moms to engage and receive free diapers.
The case manager is an experienced social worker who has been trained on perinatal care. They are integral in ensuring the engagement and the retention of the mom into the program. Integrated into the program is APH’s proprietary app MASLOW©, which is used to identify social gaps and geo-locate the closest resource. The immediate issues are identified during the initial visit. The case manager’s case load is on average 55 patients, depending on level of identified need.
The initial visit includes an assessment of need as well as identification of risk. The social worker works with the mom to help resolve the social risks and decrease any health disparities, utilizing both the health plan’s resources as well as community resources.
One example of addressing social gaps is of a 19-year-old pregnant woman who during her first home visit with the social worker expressed being very stressed about not having resources for herself and the baby during the pregnancy and beyond. She reported she recently lost her job, and every dollar is needed.
During that initial visit, the social worker worked with the patient to enroll in the health plan’s value-added services program to earn rewards for prenatal, post-partum and pediatric care. She also assisted her with enrolling in the state’s rewards program for preventative care and measures. The case manager additionally assisted the young mother by linking her to a local resource that provides parenting education and free diapers.
The mom expressed great relief with the immediate assistance she was given, which created a supportive partnership that was built upon engagement and meeting the patient where she was. Working toward the goals that are most important to her will ensure the young mom will be more likely to participate in perinatal education, medical care and follow-up visits with her case manager and the rest of the team.
The OB/GYN experienced registered nurse is responsible for the ongoing education throughout the pregnancy. They are educating based on trimester and explaining the need for routine labs, ultrasounds, provider visits and monitoring of their mental health. All education is provided based on mom’s level of health literacy. The RNs work very closely with the social workers to help monitor the patient’s adherence to their pregnancy plan and their overall well-being.
The transition of care (TOC) team reaches out following any inpatient hospitalization or emergency department visit. They are engaging within 24 hours of utilization and ensuring they set up the next steps for continuing care and needed visits. They will assure all other APH team members are notified of the transition assistance and schedule the social worker in-home visit within seven days. They will assist with scheduling of any follow-up visits with primary or specialty care.
The perinatal program duration is from time of a positive pregnancy test to one year post delivery. Nearly two of three maternal deaths in the U.S. occur during the postpartum period, up to 42 days following birth. Compared to women in the other countries, U.S. women are the least likely to have supports such as home visits and guaranteed paid leave during this critical time. Post partum depression can also go unchecked, which can impact both the health of the mom and the newborn (Commonwealth Fund, 2024).
We were able to identify a mother in crisis during a post-partum visit, four months post-delivery. The young woman is a 20-year-old who has enrolled with APH since August. When she was assessed for depression during her pregnancy, her PHQ9 score was four. She was engaged throughout her pregnancy, meeting with the case manager and the RN. She attended her prenatal provider visits and had her scheduled ultrasound and lab work.
She delivered in early November. The case manager visited her at home during the postpartum period a few weeks after delivery and her PHQ9 score had drastically risen to 23 with suicidal ideation. The APH team reached out to the patient’s therapist and helped to transition her safely to an inpatient setting. She was admitted for four days to a behavioral health clinic.
Following discharge, the TOC coordinator successfully engaged the patient during the transition. The patient stated she was grateful for all the support, and she was feeling much better. The case manager also engaged with the patient and visited her at home to ensure her stability and provide any additional supports needed.
The patient was rescreened in February and PHQ9 total score was one. The patient reported being very happy for the help and care from everyone. She was starting a new job and stated she “was in a really good place.”
The most recent in-person touchpoint with her case manager was just a couple weeks ago; the patient and baby are both doing great. She is enjoying her new job and has been more able to spend time focusing on herself with the support of her partner. She is taking her medications as prescribed and receiving behavioral health services. She is sleeping well and overall has had a marked improvement in both her mood and functioning.
Program Outcomes
Each member of the APH team is focused on assisting in whatever way they can to ensure the mom’s needs are being met and that the perinatal program requirements are being followed. The ultimate outcomes are to improve quality of life where it is needed and to ensure a safe delivery with a healthy baby.
The health plans have struggled to increase engagement with the pregnant patients. Their engagement rates were reported at approximately 5%. APH has been providing the perinatal program in New Mexico for just under a year. In that brief time, we have already seen positive results in engagement.
Patient Engagement
| Total # of patients referred from Health Plans | 9561 | |
| Initial Visits Completed | 3272 | 34.2 % engagement |
| Patients agreeing to ongoing case management | 1219 | 37.2% engagement following initial visit |
| Total in case management from total referred | 12.7% |
The measurable goals set for the APH peri-natal program are to:
- Decrease low birth weight
- Decrease pre-term births
- Decrease utilization of NICU
- Eliminate deaths of mother and newborn
| Percentage of Total Births | New Mexico State Outcomes* | ||
| Total number of births by engaged patients | 229 | ||
| Babies born underweight (< 5lb, 8oz) | 22 | 8.7% | 9.7% |
| Babies born preterm (< 36 weeks, 6 days) | 20 | 9.6% | 10.1% |
| NICU stay post birth | 20 | 8.7% | No state data available |
| Pregnancy related death | 0 | 31.02 deaths per 100,000 | |
| Infant death | 1 | .4% | 5.9% |
*Data includes all births, not just those born with Medicaid
Improving Outcomes
Maternal health is both a national and a state focus. New Mexico has created a perinatal program for their Medicaid recipients. APH has contracted with health plans in New Mexico to provide perinatal case management. The focus of the APH perinatal program is to first address all the social risks the mother and family are facing. When the issues of food and housing insecurities are addressed, the patient is then more open and able to integrate the education being offered and the care plan objectives.
APH continuously looks for ways to improve our percentage of engagement. Our goal is to have 30% of the referred population engaged in case management through delivery. We look for new opportunities to collaborate with local community agencies and providers. We listen to our patients and meet them where they are to help find solutions to their issues. Overall, we focus on improving the quality of life and well-being for both the mom and the baby.
References
CIA.gov. (2020) The World factbook. https://www.cia.gov/the-world-factbook/field/maternal-mortality-ratio/country-comparison/
Commonwealth Fund. (2024) Insights into the U.S. maternal mortality crisis: An international comparison. https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison
KFF. (2025). Custom State Reports: New Mexico. https://www.kff.org/statedata/custom-state-report/?i=32153%7C50bc2b91~32618%7C50bc2b91~32663%7C50bc2b91~32157%7C50bc2b91~32158%7C50bc2b91~32160%7C50bc2b91~32163%7C50bc2b91~32154%7C50bc2b91~544421%7C50bc2b91~558989%7C50bc2b91&g=nm&view=3
Maitreyee Sharma & Biplob Bhuyan. (2024). Examining socioeconomic factors influencing maternal health in pregnancy. Journal of Human Behavior in the Social Environment. https://doi.org/10.1080/10911359.2024.2310272
March of Dimes. (2023). New Mexico report card. https://www.marchofdimes.org/peristats/reports/new-mexico/report-card
Martinson, M., Reichman, N. (2016). Socioeconomic inequalities in low birth weight in the United States, the United Kingdom, Canada, and Australia. American Journal of Public Health 106, no. 4 (April 1, 2016): pp. 748-754 https://doi.org/10.2105/AJPH.2015.303007
New Mexico Human Services Department. (2024). Maternal health and Turquoise Care stakeholder presentation. https://www.hca.nm.gov/wp-content/uploads/Stakeholder-Presentation-1.pdf
New Mexico Human Services Department. (2024). Letter to community-based organizations: Delegation of perinatal case management. https://www.hca.nm.gov/wp-content/uploads/Maternal-Health-Letter-to-CBOs_05062024.pdf
Olds, D. L., Kitzman, H. J., Cole, R. E., et al. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending. Archives of Pediatrics & Adolescent Medicine, 164(5), 419–424. https://doi.org/10.1001/archpediatrics.2010.49
Source NM. (2023, December 4). NM far above the national maternal death rate. https://sourcenm.com/2023/12/04/nm-far-above-the-national-maternal-death-rate
U.S. Department of Health and Human Services, Maternal and Child Health Bureau (MCHB). (2024). Needs assessment update: New Mexico. https://mchb.tvisdata.hrsa.gov/Narratives/III.C.%20Needs%20Assessment%20Update/8b609333-f44b-4eeb-a392-f09e56afd404
Jayme Ambrose, DNP, RN, CCM, is the founder and CEO of Adobe Population Health, an Arizona-based company pioneering technology-driven, holistic solutions to improve health equity and care for at-risk populations. With a doctorate in Nursing Science & Leadership from Case Western Reserve University, she developed an integrated case management model that combines data-driven insights with human connection to address social determinants of health. After piloting her model at Beech Medical Group and securing her first insurance contract in 2016, Jayme acquired her division in 2018 and launched Adobe Population Health. Adobe now employs 400 healthcare professionals and serves over 400,000 patients across eight states through its innovative MASLOW™ platform and hybrid care model. Jayme is also an adjunct professor at Arizona State University and actively serves on several professional boards.
David Heinrich, BS, RN, CCM, is a results-driven healthcare professional specializing in population health management and integrated care strategies. As vice president of integrated clinical services at Adobe Population Health, he leads multidisciplinary teams delivering person-centered care across diverse communities. David brings a strong track record in improving health outcomes, reducing hospital readmissions, and advancing value-based care through data-driven initiatives, strategic partnerships and effective care coordination models.
Sarah Sandoval, BS, family child science, director of Medicaid Programs, brings over 15 years of managed care experience in New Mexico, focusing on improving healthcare access and outcomes for Medicaid populations. She has led successful initiatives in care coordination, transitions of care, and specialty population management. Sarah began her career in the non-profit sector, managing treatment foster care programs and building expertise in behavioral health and integrated care. A graduate of New Mexico State University with a BS in family child science, she is deeply committed to serving her home state. Her passion lies in creating innovative, compassionate healthcare solutions for underserved communities.
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