About MOMI PODS

• For Healthcare Partners

  Postpartum follow up rates are low, which represents a missed opportunity to improve the health of birthing individuals and their families as well as screen for and manage risk factors for severe maternal morbidity and mortality. The Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS) is an interdisciplinary, health system wide program at The Ohio State University Wexner Medical Center, funded by the Ohio Department of Medicaid’s Care Innovation and Community Improvement Program (CICIP). MOMI PODS was developed to facilitate the pregnancy to postpartum primary care transition, particularly for individuals at risk for severe maternal morbidity, via a unique multidisciplinary model of mother/infant dyadic primary care.

  MOMI PODS applies the Chronic Care Model (CCM) to integrate primary care (provided by Med-Peds, Family Medicine, and General Internal Medicine), Obstetrics, Maternal Fetal Medicine, Neonatology, pharmacy and community partners to engage patients across the pregnancy continuum to ensure seamless care transitions and care access. The program promotes prenatal and postpartum primary care engagement through evidence-based components and aligning with Ohio Department of Medicaid perinatal priorities based on patient community stakeholder feedback and aims to remove barriers of traditional primary care access, including transportation, care coordination, and increased cost.

  Process

  MOMI PODS clinicians engage patients across the pregnancy continuum to ensure seamless care transitions and care access. A nurse care coordinator provides warm handoffs between referring department/organization and primary care through an electronic health record referral system. Both birthing parent and baby are offered care by the same primary care provider during one comprehensive patient visit, overcoming time, transportation, stress, and financial barriers. For parents who already have a primary care provider for their infant but not one for themselves, we are able to provide care for birthing individuals only.

  At dyad primary care appointments, birthing parents are screened for depression, tobacco use, and chronic illness, and receive counseling, referrals and education on exercise, diet, smoking, and family planning. Breastfeeding curriculum and a culturally sensitive process for patients with modesty concerns related to lactation support was developed for MOMI PODS and is utilized by residents and lactation specialists. A GIM Clinical pharmacist coordinates pharmacy care between GIM and Family Medicine. Providers then decide how frequently birthing parents need to be seen for follow up and provide ongoing care for both parent and infant. Care coordinators help patients navigate care access as well as connect with appropriate community resources and perform regular check-ins and needs assessments.

  System

  MOMI PODS engages numerous primary care providers (PCPs) in caring for enrolled patients at Wexner Medical Center health care locations throughout Central Ohio. Participating health care locations include Family Medicine, Internal Medicine and Pediatrics, and a Federally Qualified Health Center. MOMI PODS is currently expanding its clinical care sites to additional Med-Peds sites, Outpatient Care, Family Medicine and select subspecialty sites.

  MOMI PODS has grown into a system wide program incorporating multiple departments and primary care clinics in Central Ohio with a developed workflow process and plan for referrals, scheduling, patient visits, and tracking.

  As part of quality improvement and evaluation, the program approach is routinely analyzed and updated as part of a long-term goal to establish a reproducible workflow to increase preventive postpartum care among high-risk populations.

  Benefits

  The MOMI PODS team has made significant progress towards project goals to build program operations and infrastructure for the MOMI PODS initiative while developing and delivering high quality, patient-centric engagement, and care experiences. Project goals include:

  Increase primary care follow up among mothers/infants in the first 1,000 days of life and until children are 3 years of age.

  • Develop and operationalize an innovative program to increase patient engagement through tailored health care delivery to mother/infant dyads with clinical and/or social risk factors.
  • Create best practice strategies for improving patient experience through participatory design integrated continuous quality improvement.
  • Build infrastructure to enhance medical center engagement with Ohio Medicaid Mom/Baby bundled care.

  Evaluation of the MOMI PODS dyad program has been supported by the Ohio Department of Health and Ohio Department of Medicaid.

  Eligibility

  Any birthing individual up to 3 years postpartum who needs primary care access.

  Patients “graduate” MOMI PODs at 3 years postpartum; at this time, patients maintain their primary care provider established through MOMI PODS but move into a typical clinical structure.

• For Mom and Baby

  It’s important that all birthing parents see a healthcare provider regularly after having a baby, but we know this can be difficult for a lot of people. Our clinicians at the Ohio State Wexner Medical Center can provide primary care for both you and your new baby. We offer joint appointments for both of you to be seen at the same time! A combined appointment for you and baby:

  • Saves a Trip
  • Reduces Expenses
  • Provides Quality Care for BOTH you and baby

  At your combined appointment, we will address your primary care and post-partum needs such as: breastfeeding, mental health wellness, family planning, and health conditions such as hypertension, diabetes, gestational diabetes mellitus, urinary incontinence, and gastrointestinal health. Receiving screening for these health conditions is important to stay healthy and allows you to take care of yourself and your baby.
  
  We will take care of all your baby’s well-child check visits and any additional appointments they may need. At the well child visit your doctor will do a head-to-toe exam, discuss your child’s growth and development, provide immunizations, and answer all your questions. If you already have a pediatrician for your baby but are still in need of a primary care provider for yourself, you can still enroll in our program. Our team will help you establish primary care and provide you with any necessary resources and support.
  
  MOMI PODS Clinical Nurse Care Coordinators will also be available to you to provide you with wraparound care, educational resources, and links to community resources for you and baby. If you have any questions about how to get certain resources or managing any barriers to getting the care you and your baby need, our care coordinators are there to assist you as needed as well as provide regular check-ins.
  
  Ready to learn more about MOMI PODS?
  
  Complete the MOMI PODS referral form to sign up or receive additional information about the MOMI PODS program. 
  
  Call the MOMI PODS Care Coordinators at 614-685-4403 with any questions you may have about the MOMI PODS program or the enrollment process.