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Background: Neonatal intensive care unit admission rates are an important birth outcome indicator for Medicaid managed care organizations., Objectives: To reduce neonatal intensive care unit admission rates by at least 15% and to maintain that reduction through implementation of a quality improvement program., Study Design: The organization performed a longitudinal population-based review of its birth outcomes from 1997 through 2003, focusing on neonatal intensive care unit admission rates. The return-on-investment evaluation reflected attributable incremental program costs and resultant savings., Methods: Interventions included enhanced identification and stratification of high-risk women with the use of a health risk assessment form; outreach through nursing care coordination offering home visits, transportation, support services, social work services, and connection with other community-based organizations; and implementation of a strong informatics structure., Results: Neonatal intensive care unit admission rates decreased from 107.6 per 1000 births in 1998 to 56.7 per 1000 births in 2003. The return on investment from the incremental program enhancements was just over dollars 2 per dollars 1 expended., Conclusion: A program that identifies its high-risk pregnant enrollees in a timely fashion, provides outreach using a strong nursing care coordination and social work emphasis, and has an enhanced informatics structure can significantly affect birth outcomes for a Medicaid managed care population.