The lack of continuity of health care for women after the postpartum visit can be especially problematic for women with perinatal depression (depression during pregnancy and up to 1 year postpartum). Many women have the onset of depression in the third trimester or postpartum, and 23%–46% of women with postpartum depression (PPD) continue to have symptoms for 1–2 years after follow-up (Vliegen et al., 2014Vliegen N. Casalin S. Luyten P. The course of postpartum depression: A review of longitudinal studies.Harvard Review of Psychiatry. 2014; 22: 1-22Crossref PubMed Scopus (136) Google Scholar). In addition, rates of maternal suicide peak at 6–9 months postpartum (Mangla et al., 2019Mangla K. Hoffman M.C. Trumpff C. O’Grady S. Monk C. Maternal self-harm deaths: An unrecognized and preventable outcome.American Journal of Obstetrics & Gynecology. 2019; 221: 295-303Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar; Metz et al., 2016Metz T.D. Rovner P. Hoffman M.C. Allshouse A.A. Beckwith K.M. Binswanger I.A. Maternal deaths from suicide and overdose in Colorado, 2004–2012.Obstetrics and Gynecology. 2016; 128: 1233Crossref PubMed Scopus (95) Google Scholar). Lack of health care continuity in the critical postpartum period, therefore, can have negative implications for maternal and child health. Ten percent to 20% of women experience perinatal depression, but only 4% of women with perinatal depression are treated to remission (Cox et al., 2016Cox E.Q. Sowa N.A. Meltzer-Brody S.E. Gaynes B.N. The perinatal depression treatment cascade: baby steps toward improving outcomes.Journal of Clinical Psychiatry. 2016; 77: 1189-1200Crossref PubMed Scopus (109) Google Scholar). Black and Latina women are less likely to initiate postpartum mental health care, and less likely than White women to receive follow-up treatment or continued care (Kozhimannil et al., 2011Kozhimannil K.B. Trinacty C.M. Busch A.B. Huskamp H.A. Adams A.S. Racial and ethnic disparities in postpartum depression care among low-income women.Psychiatric Services. 2011; 62: 619-625Crossref PubMed Scopus (112) Google Scholar). Integrating mental health treatments into obstetric settings can improve access during pregnancy (Byatt et al., 2019Byatt N. Xu W. Levin L.L. Moore Simas T.A. Perinatal depression care pathway for obstetric settings.International Review of Psychiatry. 2019; 31: 210-228Crossref PubMed Scopus (19) Google Scholar), but it is challenging to ensure continuity of mental health care after delivery. Women often experience interruptions in health care after delivery, and the interruptions in care can be especially challenging for women with low incomes. In states without Medicaid expansion, pregnancy coverage often ends on the last day of the month in which the 60-day postpartum period ends. In states that have opted into Medicaid expansion, women can enroll in standard Medicaid, Marketplace coverage, or employer-sponsored coverage when pregnancy coverage ends, but these options often do not offer the enhanced benefits available under pregnancy Medicaid (Johnson et al., 2020Johnson K. Rosenbaum S. Handley M. The next steps to advance maternal and child health in Medicaid: Filling gaps in postpartum coverage and newborn enrollment.Health Affairs. 2020; (Available:)www.healthaffairs.org/do/10.1377/hblog20191230.967912/full/Date accessed: August 12, 2020Google Scholar). Women insured by Medicaid have high rates of drop in care in the postpartum period, with only 60% of women attending their 6-week postpartum check (Weir et al., 2011Weir S. Posner H.E. Zhang J. Willis G. Baxter J.D. Clark R.E. Predictors of prenatal and postpartum care adequacy in a Medicaid managed care population.Women's Health Issues. 2011; 21: 277-285Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar). Even fewer women have continuity of care beyond the 6-week postpartum visit (Kozhimannil and Fontaine, 2013Kozhimannil K.B. Fontaine P. Care from family physicians reported by pregnant women in the United States.Annals of Family Medicine. 2013; 11: 350-354Crossref PubMed Scopus (23) Google Scholar). This commentary discusses the implications of the postpartum care transition for mental health care and makes recommendations for future research and policy changes. Pregnancy is traditionally viewed as an “episode” of care, and many women do not receive obstetric care after the routine postpartum visit that occurs 6–8 weeks after delivery. Episodic pregnancy care can be at odds with the nature of depression, which is a chronic and recurring disorder. Inadequate care transitions can result in missed identification of mental health problems or lack of continuity of mental health care that was initiated in the prenatal setting (Katon et al., 2017Katon J.G. Lewis L. Hercinovic S. McNab A. Fortney J. Rose S.M. Improving perinatal mental health care for women veterans: Description of a quality improvement program.Maternal and Child Health Journal. 2017; : 1-8Google Scholar). This issue might be more easily addressed in family medicine settings or Federally Qualified Health Centers, where patients often continue to seek care for themselves and their children after delivery. Approximately one-third of pregnant women report receiving care from a family medicine physician at some time during their pregnancy, although it is unclear whether women consulted family physicians for general primary care, prenatal care, or other health services (Kozhimannil and Fontaine, 2013Kozhimannil K.B. Fontaine P. Care from family physicians reported by pregnant women in the United States.Annals of Family Medicine. 2013; 11: 350-354Crossref PubMed Scopus (23) Google Scholar). Women who receive prenatal care in obstetric settings may find themselves “homeless” with respect to medical and mental health care after their 6-week visit with their prenatal provider. We list here potential ways to support uninterrupted treatment for perinatal depression, especially in the context of integrated care models. Integrated mental health treatments such as the perinatal collaborative care model (CoCM) can improve depression treatment access and outcomes (Grote et al., 2015Grote N.K. Katon W.J. Russo J.E. Lohr M.J. Curran M. Galvin E. Carson K. Collaborative care for perinatal depression in socioeconomically disadvantaged women: A randomized trial.Depression and Anxiety. 2015; 32: 821-834Crossref PubMed Scopus (74) Google Scholar). In the perinatal CoCM, a psychiatric consultant reviews the care of a panel of patients with a care manager (CM) and makes treatment recommendations based on the CM assessment. These recommendations are communicated to the obstetric clinicians who are primarily responsible for mental health care. Only women with complex psychiatric conditions are seen in person by the psychiatrist, thus ensuring access to higher level services for those who need it most. The CM is in the obstetric clinic, and collects and tracks data, such as depression symptom measures, in a registry. CMs serve as the patient's primary contact for mental health needs, monitoring outcomes, following up between visits, providing evidence-based psychotherapy, and collaborating with the primary care or prenatal provider. Perinatal CoCM can improve access to high-quality mental health care, is effective in improving depressive symptoms, is cost effective, is acceptable to patients, and is reimbursed by a number of payors (American Psychiatric Association, 2019American Psychiatric AssociationGetting paid in the collaborative care model.2019www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/get-paidDate accessed: August 12, 2020Google Scholar; Bhat et al., 2018Bhat A. Reed S. Mao J. Vredevoogd M. Russo J. Unger J. Unützer J. Delivering perinatal depression care in a rural obstetric setting: A mixed methods study of feasibility, acceptability and effectiveness.Journal of Psychosomatic Obstetrics and Gynecology. 2018; 39: 273-280Crossref PubMed Scopus (9) Google Scholar). When compared with other populations, the perinatal period presents several features supportive of CoCM implementation. Frequent follow-up in the perinatal period (with 10–15 visits during pregnancy and 1–2 visits postpartum for “low-risk” pregnancies) provides an ideal framework for repeated administration of validated depression symptom measures such as the Patient Health Questionnaire-9 (Kroenke et al., 2001Kroenke K. Spitzer R.L. Williams J.B.W. The PHQ-9: Validity of a brief depression severity measure.Journal of General Internal Medicine. 2001; 16: 606-613Crossref PubMed Scopus (19891) Google Scholar) or the Edinburgh Postnatal Depression Scale (Cox et al., 1987Cox J.L. Holden J.M. Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale.British Journal of Psychiatry. 1987; 150: 782-786Crossref PubMed Scopus (8337) Google Scholar). Regular measurement of symptoms is a cornerstone of the perinatal CoCM and serves two functions: repeat screening to detect incident cases of depression, and measurement of symptoms in established cases of depression to track symptom trajectories and provide stepped care treatment recommendations. One example of a perinatal CoCM program is COMPASS at Northwestern University (Compass Program, 2019Compass ProgramNorthwestern.2019www.nm.org/conditions-and-care-areas/womens-health/obgyn/obstetrics/postnatal-care/compassDate accessed: August 12, 2020Google Scholar). All pregnant and postpartum women are eligible for CoCM and all enrolled women are followed for 1 year after delivery. This system is designed to achieve stabilization during pregnancy and 1 year postpartum, with plans for referral to ongoing care after that point for women with ongoing mental health needs. The team based CoCM approach with CM outreach and follow-up decreases the burden on the prenatal provider and ensures that the short duration of prenatal and postpartum visits is not a barrier to delivering mental health treatment. Data from the COMPASS program (E. Miller, personal communication, 22 January 2020) show that of 1,553 women referred to COMPASS over 1 year, 761 (49%) were referred postpartum. Of women referred postpartum, 266 (35%) were referred after 8 weeks postpartum and 84 (11%) were referred after 12 weeks postpartum. Therefore, extending care through 1 year postpartum has expanded access to more women. Many obstetric clinicians consider themselves to be primary care providers (PCPs), and women consider their obstetric clinicians their PCPs as well (Melville et al., 2014Melville J.L. Reed S.D. Russo J. Croicu C.A. Ludman E. LaRocco-Cockburn A. Katon W. Improving care for depression in obstetrics and gynecology: A randomized controlled trial.Obstetrics and Gynecology. 2014; 123: 1237-1246Crossref PubMed Scopus (70) Google Scholar). Yet, not all obstetric clinicians have the same treatment philosophy or approach and may not manage depression after the immediate postpartum period, and this necessitates a postpartum care transition. Although there should ideally be a warm hand off to a PCP (a primary care practice with integrated mental health would be ideal) at the 6-week postpartum visit, fewer than 33% of women nationally transition to a PCP within the year after childbirth (Bennett et al., 2014Bennett W.L. Chang H.-Y. Levine D.M. Wang L. Neale D. Werner E.F. Clark J.M. Utilization of primary and obstetric care after medically complicated pregnancies: An analysis of medical claims data.Journal of General Internal Medicine. 2014; 29: 636-645Crossref PubMed Scopus (96) Google Scholar). The Committee Opinion from the American Colleges of Obstetricians and Gynecologists and the Association of Women's Health, Obstetric and Neonatal Nurses recommends that anticipatory guidance for the postpartum period begin during pregnancy, with the patient and their obstetric clinician identifying the transition plan for health care in the postpartum period. It also reinforces the importance of the “fourth trimester” and the concept of ongoing postpartum care rather than a one-time visit (American College of Obstetricians and Gynecologists Committee on Obstetric Practice, 2016American College of Obstetricians and Gynecologists Committee on Obstetric PracticeCommittee opinion no. 666: Optimizing postpartum care.Obstetrics and Gynecology. 2016; 127: e187Crossref PubMed Scopus (67) Google Scholar). Supporting the identification of a PCP early in pregnancy for all pregnant patients will decrease the risk of postpartum gaps in care. Conversations by obstetric clinicians with patients regarding postpartum transition of care to a PCP, providing written information to the patient, and assisting patients in finding a PCP can increase the rates of postpartum transition to a PCP (Matthews, 2016Matthews C.J. A systems intervention for the transition of postpartum women to primary care.2016https://www.congress.gov/bill/116th-congress/house-bill/4996?q=%7B%22search%22%3A%5B%22H.R.4996%22%5D%7D&s=1&r=1Date accessed: August 12, 2020Google Scholar). It is well-documented that women have higher rates of attending their child's well-child visit than of attending their own postpartum visit, and this is especially true for women insured by Medicaid (Van Berckelaer et al., 2011Van Berckelaer A.C. Mitra N. Pati S. Predictors of well child care adherence over time in a cohort of urban Medicaid-eligible infants.BMC Pediatrics. 2011; 11: 36Crossref PubMed Scopus (17) Google Scholar; Weir et al., 2011Weir S. Posner H.E. Zhang J. Willis G. Baxter J.D. Clark R.E. Predictors of prenatal and postpartum care adequacy in a Medicaid managed care population.Women's Health Issues. 2011; 21: 277-285Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar). The American Academy of Pediatrics recommends that pediatricians screen for maternal PPD at the 1-, 2-, 4-, and 6-month well-child visit (Earls, 2010Earls M.F. Committee on Psychosocial Aspects of Child and Family Health American Academy of PediatricsIncorporating recognition and management of perinatal and postpartum depression into pediatric practice.Pediatrics. 2010; 126: 1032-1039Crossref PubMed Scopus (324) Google Scholar). Approaches to a positive PPD screen in pediatric settings vary, and include clinical decision support algorithms and local resource and referral lists (Waldrop et al., 2018Waldrop J. Ledford A. Perry L.C. Beeber L.S. Developing a postpartum depression screening and referral procedure in pediatric primary care.Journal of Pediatric Health Care. 2018; 32: e67-e73Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar), care management based on risk profiles and responsiveness (Olin et al., 2017Olin S.-c. S. McCord M. Stein R.E. Kerker B.D. Weiss D. Hoagwood K.E. Horwitz S.M. Beyond screening: A stepped care pathway for managing postpartum depression in pediatric settings.Journal of Women's Health. 2017; 26: 966-975Crossref PubMed Scopus (17) Google Scholar), and embedded adult psychiatrists or co-located care (Young et al., 2019Young C.A. Burnett H. Ballinger A. Castro G. Steinberg S. Nau M. Beck A.L. Embedded maternal mental health care in a pediatric primary care clinic: A qualitative exploration of mothers’ experiences.Academic Pediatrics. 2019; 19: 934-941Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar). Given the health care utilization patterns of new parents, with up to 7 well-child visits in the first year of life (Kerker et al., 2016Kerker B.D. Storfer-Isser A. Stein R.E. Garner A. Szilagyi M. O'Connor K.G. Horwitz S.M. Identifying maternal depression in pediatric primary care: Changes over a decade.Journal of Developmental and Behavioral Pediatrics. 2016; 37: 113Crossref PubMed Scopus (29) Google Scholar), pediatric offices have the ability to help address postpartum gaps in mental health treatment for parents. Many women with a low incomes who are at higher risk for perinatal mental health problems receive home visiting services. Some home visiting services utilize protocols to screen for and refer women for mental health problems (Ammerman et al., 2010Ammerman R.T. Putnam F.W. Bosse N.R. Teeters A.R. Van Ginkel J.B. Maternal depression in home visitation: A systematic review.Aggression and Violent Behavior. 2010; 15: 191-200Crossref PubMed Scopus (103) Google Scholar) or provide integrated mental health treatment (Ammerman et al., 2014Ammerman R.T. Putnam F.W. Teeters A.R. Van Ginkel J.B. Moving beyond depression: A collaborative approach to treating depressed mothers in home visiting programs.Zero to Three. 2014; 34: 20-27Google Scholar). Maternity support services or enhanced prenatal care programs funded by state Medicaid programs can also improve access to mental health treatments (Kroll-Desrosiers et al., 2015Kroll-Desrosiers A.R. Crawford S.L. Moore Simas T.A. Rosen A.K. Mattocks K.M. Improving pregnancy outcomes through maternity care coordination: A systematic review.Womens Health Issues. 2015; 26: 87-99Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). However, physicians and prenatal providers may not be aware of these additional services, leading to reduced utilization of the enhanced services, or a lack of coordination between clinical and community-based services (Raffo et al., 2014Raffo J.E. Gary M. Forde G.K. Meghea C.I. Roman L.A. Physician awareness of enhanced prenatal services for Medicaid-insured pregnant women.Journal of Public Health Management and Practice. 2014; 20: 236-239Crossref PubMed Scopus (2) Google Scholar). Prenatal providers can help bridge the postpartum gap by coordinating care with home visiting programs, exchanging treatment plans and symptom measures with the patient's consent. Payment for prenatal care is often in the form of bundled payments, a single, fixed payment for a group of services provided to treat a condition during a defined episode of care. However, most prenatal bundles apply only to low-risk pregnancies and do not provide for the added services that mental health care requires. Given the high prevalence of perinatal depression, there is an urgent need to incentivize provision of mental health care and provide structured guidance for obstetric practices on how to bill for the mental health screening and treatment services that they provide. Obstetric practices using bundled payments for maternity care could bill CoCM codes separately and in addition to the bundled payment. (CoCM codes are reimbursed by Medicaid in several states [American Psychiatric Association, 2019American Psychiatric AssociationGetting paid in the collaborative care model.2019www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/get-paidDate accessed: August 12, 2020Google Scholar]). Additional obstetric visits for depression management in the postpartum period can also be billed as added on evaluation and management encounters. Many state Medicaid programs reimburse caregiver depression screening during well child visits (Center for Medicaid and CHIP Services, 2016Center for Medicaid and CHIP ServicesMay 11Maternal depression screening and treatment: A critical role for Medicaid in the care of mothers and children.www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdfDate: 2016Date accessed: August 12, 2020Google Scholar); however, no data are available on reimbursement strategies for PPD treatment programs in pediatric settings (Olin et al., 2015Olin S.S. Kerker B. Stein R.E. Weiss D. Whitmyre E.D. Hoagwood K. Horwitz S.M. Can postpartum depression be managed in pediatric primary care?.Journal of Women's Health. 2016; 25: 381-390Crossref PubMed Scopus (21) Google Scholar). Ensuring high-quality and uninterrupted treatment for perinatal mental health disorders will require concerted efforts from multiple stakeholders—prenatal, primary care, pediatric, public health and allied health providers, payors, and policymakers. Both the CoCM and patient-centered medical homes are grounded in the chronic care model (Wagner et al., 1996Wagner E.H. Austin B.T. Von Korff M. Organizing care for patients with chronic illness.Milbank Quarterly. 1996; : 511-544Crossref PubMed Scopus (2101) Google Scholar) and include principles of coordination and comprehensiveness of care, continuity, access, using evidence-based treatments, and quality improvement methods (Unützer et al., 2013Unützer J. Harbin H. Schoenbaum M. Druss B. The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Health Home, Information Resource Center, 2013: 1-13http://www.chcs.org/media/HH_IRC_Collaborative_Care_Model__052113_2.pdfDate accessed: August 12, 2020Google Scholar). If applied to perinatal mental health treatments, these principles could help to decrease maternal morbidity and mortality, and increase patient and provider satisfaction. The support that a patient-centered medical home can provide for people with mental health conditions has been described for general adult (Starfield and Shi, 2004Starfield B. Shi L. The medical home, access to care, and insurance: A review of evidence.Pediatrics. 2004; 113: 1493-1498PubMed Google Scholar) and pediatric populations (Asarnow et al., 2017Asarnow J.R. Kolko D.J. Miranda J. Kazak A.E. The pediatric patient-centered medical home: Innovative models for improving behavioral health.American Psychologist. 2017; 72: 13Crossref PubMed Scopus (65) Google Scholar); this could be used as a template for patient centered maternity care, which includes attention to mental health. Evaluations of pregnancy centered medical home pilot programs have shown improved pregnancy outcomes (Berrien et al., 2015Berrien K. Ollendorff A. Menard M.K. Pregnancy medical home care pathways improve quality of perinatal care and birth outcomes.North Carolina Medical Journal. 2015; 76: 263-266Crossref PubMed Scopus (7) Google Scholar), but these programs do not yet define how mental and behavioral health fits into this model. The management of perinatal psychiatric conditions requires a multidisciplinary approach involving members from various care teams that may include obstetric clinicians, maternal fetal medicine clinicians, psychiatry, social work, nursing, and pediatrics, to name just a few. We have highlighted the need for a more integrated system of care between obstetrics and pediatrics, and Medicaid enhanced prenatal services and prenatal clinical care (Raffo et al., 2014Raffo J.E. Gary M. Forde G.K. Meghea C.I. Roman L.A. Physician awareness of enhanced prenatal services for Medicaid-insured pregnant women.Journal of Public Health Management and Practice. 2014; 20: 236-239Crossref PubMed Scopus (2) Google Scholar). Early experiences from perinatal CoCM programs such as COMPASS demonstrate that extending the duration of the postpartum period beyond the traditionally defined 6 weeks can expand mental health treatment access to more women in need. Careful documentation of time and resources invested, billing procedures adopted, patient outcomes, and patient and provider satisfaction will be imperative in making the case for wider implementation of this approach. However, this integrated mental health approach may not be possible in all settings. In these cases, we recommend close collaboration and care coordination with other health care and community-based providers who support women in the postpartum period, such as pediatric providers and home visiting nurses. In all cases, discussions about establishing or continuing primary care in the postpartum period must begin during pregnancy, and the 6-week postpartum visit must be used to link women to ongoing primary care. As we recognize the importance of maternal mental health for maternal and child outcomes and we reconceptualize how long the postpartum period lasts, there may also be a need to restructure how we reimburse perinatal health care services. One option could include having these high-risk pregnancies (related to mental health) take the form of a “layered bundle,” which would cover the additional care needed. Examples of this extra care include additional visits related to mental health care and extending postpartum care services up to 6–12 months postpartum. Quality metrics added on could include depression screening rates and linkage to mental health resources. Another important policy change would be expanding pregnancy insurance coverage to one year postpartum. Recently, California implemented the Provisional Postpartum Care Extension program (Provisional Postpartum Care Extension, 2020Provisional Postpartum Care Extension. 2020https://www.congress.gov/bill/116th-congress/house-bill/4996?q=%7B%22search%22%3A%5B%22H.R.4996%22%5D%7D&s=1&r=1Date accessed: August 12, 2020Google Scholar) extending MediCal coverage to 1 year postpartum for individuals with maternal mental health conditions. The pending bill Helping MOMS Act of 2019 (“H.R. 4996, 2019H.R. 4996Helping MOMS Act of 2019.2019https://www.congress.gov/bill/116th-congress/house-bill/4996?q=%7B%22search%22%3A%5B%22H.R.4996%22%5D%7D&s=1&r=1Date accessed: August 12, 2020Google Scholar”) would also allow states to provide one year of postpartum coverage. Policy changes such as these can help to decrease racial–ethnic disparities in insurance disruptions experienced by Hispanic, Black, and indigenous women who are disproportionally enrolled in pregnancy Medicaid and experience higher rates of loss of insurance in the postpartum period (Daw et al., 2020Daw J.R. Kolenic G.E. Dalton V.K. Zivin K. Winkelman T. Kozhimannil K.B. Admon L.K. Racial and ethnic disparities in perinatal insurance coverage.Obstetrics and Gynecology. 2020; 135: 917Crossref PubMed Scopus (19) Google Scholar). Redesigning the way prenatal and postpartum care is provided is a complex undertaking, and ensuring continuity of high-quality mental health care in the postpartum period can be difficult, but it is time to find a medical home for women with perinatal depression. This will mean disrupting workflows and innovating on payment mechanisms in the short term, but it is a small price to pay for the health of women and our future generations. Amritha Bhat, MD, MPH, is Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington. Her areas of expertise include perinatal psychiatry and collaborative care. Her research involves developing integrated mental health care models that include attention to the parent-infant dyad. Emily S. Miller, MD, MPH, is Assistant Professor, Departments of Obstetrics and Gynecology and Psychiatry and Behavioral Sciences, Northwestern University. She has expertise in health services to optimize perinatal mental health care, with a specific focus on implementation of perinatal collaborative care. Amelia Wendt, MD, is a third-year resident in the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. She is a member of the Perinatal Psychiatry pathway, actively involved in interdisciplinary resident education, and presented nationally on perinatal behavioral health topics. Anna Ratzliff, MD, PhD, is a Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. She is the director of the residency training program and co director of the AIMS center. Her expertise is in collaborative care and interprofessional education.