In January 2018, Michigan’s Medicaid provider manual was updated to include maternal depression screening as part of its guidance related to Early and Periodic Screening, Diagnosis and Treatment (EPSDT). According to this guidance, the child’s primary care provider should conduct this screening during well-child visits at 1, 2, 4, and 6 months, as recommended by the American Academy of Pediatrics. The maternal depression screening is billed under the child’s Medicaid using Current Procedural Terminology code 96161, which covers administration of a health risk screening with a standardized tool, for the benefit of the child. The Edinburgh Postnatal Depression Scale (EPDS) is offered as an example in Michigan’s guidance.
In the event of a positive screen, pediatric providers may refer the mother and infant to the Maternal Infant Health Program (MIHP), which is a home visiting program for Medicaid eligible pregnant women and infants up to age one. MIHP teams, which operate in every county of the state, must include a licensed social worker and a registered nurse. The MIHP teams can also include an infant mental health (IMH) specialist, who must be a licensed clinician with endorsement by the Michigan Association for Infant Mental Health (Infant Family Specialist required, Infant Mental Health Specialist preferred) and may provide brief mental health interventions.
MIHP providers are required to participate in webinar training on maternal depression. This training includes information on referral for evaluation and treatment to community mental health services, maternal depression symptoms and their negative impacts on parenting, the infant-parent relationship, and the child’s development. The training also provides extensive guidance for initial re-screening of parents and infants, and referrals to mental health services.
MIHP visits to the family continue through pregnancy and the child’s first 12 months. The mother receives up to nine visits during pregnancy and up to an additional nine visits during the child’s first year, with additional visits ordered by a physician as necessary. For each mother, a specific member of the MIHP team is designated the care coordinator, responsible for monitoring and coordinating all care, referrals, and follow-up services. MIHP providers follow up within three visits after any referral for maternal depression is made and help mothers address barriers to engaging in treatment. Mothers at moderate or high risk for depression are referred to a range of services, including cognitive behavioral therapy, medication, dyadic therapy, and Infant Mental Health (IMH) services (described below). IMH has worked with MIHP to educate home visitors about referring to IMH and establishing relationships with local IMH providers. MIHP has also issued guidance on when to refer to IMH. In addition to maternal depression, reasons for referral include evidence of maternal substance abuse and concerning maternal behavior, such as difficulty consoling infant or failure to respond to infant’s needs.
IMH is a statewide Medicaid-funded home visiting program for families facing multiple risks, including maternal depression, that threaten the parent-infant attachment and development of the infant. Visits are conducted weekly, or more often as needed, by a Masters-level early childhood mental health professional who must be endorsed at Level 2 by the Michigan Association of Infant Mental Health, with Level 3 preferred. A major feature of the model is the delivery of dyadic Infant-Parent Psychotherapy, with others components including support for the family’s material needs, offering emotional support, and providing developmental guidance.
There are eight Maternal Infant Health Programs that have an IMH provider as part of their program (a total of 11 IMH providers). IMH providers are not shared across the MIHPs, but it would be feasible for an IMH provider to work with more than one MIHP. During fiscal year 2018, the MIHPs served 13,483 pregnant women and 17,549 infants, and IMH services were delivered to 878 mothers and 1,915 children.
In fiscal year 2017, Medicaid funding for MIHP was $18.3 million, with $12.4 million coming from the federal government and the remaining $5.9 million coming from state matching funds. Infant Mental Health services funding was $4.7 million from federal Medicaid funding and $2.5 million from state general funds.
Monitoring and Evaluation
The state’s Medicaid program is still collecting initial data on screenings after issuing the 2018 guidance on maternal depression screening and will analyze results after a year of data collection. The state produces an annual report on its home visiting programs, with one of its indicators focusing on maternal depression referrals. The indicator does not break down the referral rates by particular home visiting programs (e.g., MIHP).
A quasi-experimental evaluation of all Medicaid-covered mothers and infants born from 2009 through 2012 found that MIHP participants were more likely to “receive a depression diagnosis or have an initial depression treatment claim, have at least 1 follow up visit, and get continued depression care with at least three additional visits during a 120 day period when compared to women not in MIHP.”
IMH is currently undergoing a comprehensive evaluation, including two community-based, quasi-experimental studies and a university-based randomized control trial, to establish it as an evidence-based model to meet state (Michigan Public Act 291 for Voluntary Home Visiting Programs) and federal (Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program) funding eligibility requirements.
Special thanks to Mary Ludtke, Innovative Services Section Manager, Michigan Department of Health and Human Services, Mental Health Services to Children and Families, for providing information for and reviewing this profile