Case Management Corner: Improving Post-Partum Discharge Outcomes

By Kelly Bilodeau

When a new mother leaves the hospital, it doesn’t just mark the end of a hospital stay; it’s the beginning of a complex, decades-long relationship.‍‍ ‍

Recovery from childbirth often occurs alongside around-the-clock care for an infant, and many variables affect the success of the transition, including the physical and mental health of the mother, the support structure at home, and the temperament and health of the baby. This means that there’s really no such thing as a routine discharge after childbirth, said Kalie Wolfinger, LCSW, manager of clinical services at Phoenix Medical Management.

The transition home also marks a crucial window when case managers and social workers can intervene to improve outcomes in mother and baby pairs. But doing so may require additional training and a rethinking of traditional discharge procedures, Wolfinger said.

Traditional hospital discharges prioritize checklists and narrow safety-based education on topics such as safe sleep strategies and car seat safety. But they often don’t focus on other critical strategies such as up-close patient mental health assessments, promoting bonding and attachment, and looking for signs of past trauma that may hinder healthy parenting, Wolfinger said.

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Maternal challenges linked to poorer outcomes

Maternal health issues are common in the weeks and months after birth, and can affect a child’s short- and long-term trajectory. As many as 20% of women who have given birth experience symptoms of postpartum depression, according to Brown University Health, and rates of the disorder have doubled over the last decade, according to a JAMA analysis. It’s not just an issue that affects the mother. One 2025 study found that infants whose mothers experienced postpartum depression had double the risk for developmental delays during the first year.

Other common issues that social workers and case managers should screen for include:  

• Maternal anxiety

• Substance use disorders

• Intimate partner violence

• Social determinants of health (e.g. poverty, housing insecurity)

Social workers and case managers can assess patients for these risk factors using a  trauma-informed and culturally sensitive approach. Observation helps gauge maternal-infant bonding and interactions.

Building infrastructure for better transitions

Providing this type of critical assistance to mothers goes beyond traditional discharge planning. It’s not just about ensuring equipment is ordered, prescriptions are filled, and follow-up visits are scheduled, but about creating bridges for patients to access outpatient services and early intervention, Wolfinger said.‍‍

It’s not always easy to create these ties, because structural barriers often get in the way. Hospital systems often don’t support this type of work and community resources may be fragmented, she said.‍‍

Social workers and case managers can also encounter thorny legal issues. It’s a delicate balance to prioritize maternal rights while safeguarding infant wellbeing. Hospitals often have standardized protocols and risk management guidelines to reduce the potential for errors and protect against potential liability, but trained professionals also need to be able to rely on their own gut instincts during patient interactions, Wolfinger said. ‍‍

Mothers may also have a disincentive to share concerns about their mental health or substance use disorders with caregivers, fearing that doing so may trigger mandatory reporting requirements or intervention from child protective services.

Specialized training can equip professionals with the tools they need to navigate these issues, ensuring better support for at-risk mother and child pairs. “Getting it wrong can have long-term consequences,” Wolfinger said. “But getting it right can have a major impact on both mom and baby over time.”

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.