CLOSING THE MATERNAL HEALTH EQUITY GAP
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FROM THE NACHC LENS
Using Self-Measured Blood Pressure Monitoring with OB Patients
The risk of serious illness to mothers and babies associated with hypertension in pregnancy are well-established. One strategy health centers are employing with pregnant patients, especially those who are high risk for hypertensive disorders, such as preeclampsia, is the use of a self-measured blood pressure (SMBP) device.
Two barriers making it difficult for pregnant women to their get to their prenatal appointments are transportation and lack of childcare. SMBP devices allow at-risk patients and care teams to regularly monitor for blood pressure fluctuations, and manage care and treatment without scheduling additional appointments or if the patient is unable to come in for their scheduled appointments.
“Having the ability to more frequently monitor our pregnant patients’ blood pressure has enabled us to identify issues sooner,” says Pat Young, OB-GYN Clinical Care Coordinator, Hometown Health, Schenectady, NY, who shared how a recent pregnant patient with borderline high blood pressure, called the health center with a significantly elevated reading. Care team staff were able to help get her to a hospital immediately where she safely delivered without complications.
Hometown Health has been growing and refining their maternal health SMBP program since 2017. Over the years, they have worked through several challenges including:
- Limited supplies
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Initial time constraints for “loaning” SMBP devices to maternal health patients
- Lack of insurance coverage for patients without a hypertension diagnosis
With a grant from an insurance provider, all high-risk OB patients can own a digital blood pressure device and self-monitor through postpartum.
Champions and Education are Critical to Implementation
In February 2020, Lisa Green, DO, MPH, CEO and Co-Founder, Family Christian Health Center, Harvey, IL, along with a group of Black women OB-GYN physicians and nonprofit leaders held a Facebook Live event addressing health disparities and unique challenges of the birthing population on the South Side of Chicago and South Suburban Cook County; amid an alarming trend of hospitals discontinuing inpatient obstetric services and an unprecedented global pandemic. Dr. Green explained the urgent need to have blood pressure devices for each OB patient and gained the attention of the state's Department of Health & Human Services. Now, all OB patients on Medicaid are given a blood pressure device to take home.
“About 70% of our OB patients are at high risk for hypertension and preeclampsia, so giving our patients the ability to monitor at home and call us to help them manage their blood pressure has been tremendous,” says Dr. Green. The health center launched its SMBP cuff program for pregnant patients in 2020.
Incorporating the SMBP program into routine patient care requires educating both staff and patients to get their buy-in. “Your staff becomes your champions,” says Dr. Green. “Your nurses and MAs are the ones who take the patient’s blood pressure, not the physician, so getting them on board is key.”
To preserve time for nurses and MAs, the health center first allowed nursing students and then community health workers to implement the program to teach patients how to use the SMBP devices. They spend time helping patients become advocates for themselves and gain a voice in their health care.
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Looking to Launch a SMBP Program for OB Patients?
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Plan for data collection with your EHR vendor to ensure proper data workflows are created in advance, and the EHR can be updated to collect the data.
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Have champions in place at all levels—from nursing and MAs to senior leadership.
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Only measuring blood pressure at home is not evidenced-based. A SMBP program needs to include patient education, outreach support, and a feedback loop to the care team for any needed treatment decisions.
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Learn the reimbursement codes for SMBP patient training and education data management for clinical decision-making. Read the 7-step SMBP quick guide to learn more.
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Expand patient education beyond blood pressure monitoring instructions. Help them overcome fears, answer questions, and break down information for them in a way they will understand.
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Purchase SMBP devices that have been clinically validated for use on pregnant people. Learn more at the U.S. Blood Pressure Validated Device Listing.
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Strengthening Health IT to Improve Postpartum Care
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As part of its mission to support access to care through community health centers, OCHIN, Portland, OR, a national nonprofit focused on equitable health care innovation who leads the nation's largest health controlled center network (HCCN), is working with Clinica Romero, Los Angeles; TrueCare, San Diego; LifeLong Medical Care, Oakland, CA; Monterey County Health Department, Monterey, CA; and Southern Jersey Family Medical Centers Inc., Hammonton, NJ; to improve maternal care of postpartum patients.
OCHIN and these health centers have developed strategies to generate high-quality data and improve workflow and EHR in support of clinical decision making associated with postpartum gestational diabetes, contraceptive counseling, depression, and anemia.
Postpartum data collection and management challenging these health centers include:
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Clinician under-compliance with necessary screening and documentation
- Consistent longitudinal data collection for contraceptive care
- Reporting needs for the data that is collected, and
- Longer time documenting care
“The most important discussions we had with our health center partners were around gaps in care and streamlined solutions,” says Michele Whitt, MD, MS, MBA, FACOG, Medical Informaticist, OCHIN. “We were cognizant of burdens on providers and did not want to create additional work. We also wanted to standardize care to advance health equity.”
All EHR tools were specifically created to address gaps in postpartum care. OCHIN addressed data capture by creating:
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Express Lane order set for contraceptive care and postpartum depression screening. The Express Lane with a SmartForm gathers information from different locations within a health center’s EHR. It contains structured notes, medication orders, special orders, procedure orders, patient education, and follow-up information.
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Best practices advisory for postpartum gestational diabetes monitoring that reminds clinicians of necessary diabetes follow-up based on clinical standards.
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Postnatal navigator to remind providers to screen for depression and address potential anemia.
For health centers looking to develop an EHR Express Lane to close care and data gaps for postpartum care, consider these tips:
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Develop all pieces of the SmartForm based on best-practice standards for postnatal care with the end-users/providers.
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Allow for a comprehensive list of medications and procedures, because user versions of the SmartForm can be created to streamline clinician options.
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Monitor use of the SmartForm to see if certain parts need revisions.
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Educate those who do not want to use the SmartForm that they may decline the prompt.
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Lisa Green, DO, MPH, CEO, and
Co-Founder, Family Christian Health Center
Harvey, IL is about a 30-minute drive from downtown Chicago, but with public transportation, an hour and half drive for the majority of its residents needing health services not available locally . However, now within this community, you will find a very special safe haven for pregnant women. Under the leadership and vision of Dr. Green, the health center opened its new Maternal Child Health + Wellness Center.
“I saw the data and knew something had to change for the pregnant women in our community - a majority of whom are at risk for health complications. We had to begin to bridge and close this health inequity gap impacting the health of our pregnant women,” says Dr. Green.
Maternal Child Health + Wellness offers women a whole ecosystem of care led by five Black and Latino OB-GYNs and a Maternal Fetal Medicine team for high-risk patients. Services offered include:
- onsite lab services
- postpartum and pediatric care
- behavioral health
- case managers connecting housing and daycare programs, etc.
- Pregnancy Centering program
Soon the health center will offer Level 2 Ultrasound onsite. This is a key maternal fetal health service provided, so women won’t have to leave the community to get it.
The environment of this Maternal Child Health + Wellness Center is as important as the services offered. When patients step inside, they enter a beautiful, warm, and welcoming space filled with colorful paintings, a floor to ceiling waterfall, refreshment credenza, patient education specifically for women, and soothing music. It is a calm, tranquil, and welcoming environment.
Without any marketing, the Maternal Child Health + Wellness Center has quickly grown. It now serves between 500-800 patients every month, representing 50 percent of deliveries from the neighboring hospital. In 2022 alone, the health center reported very positive impact:
- 254 deliveries
- 608 new OB intakes
- 3,275 patients utilized case management resources
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Building Community and Empowering Voices
Through Group Prenatal Care
One of the health center’s most unique programs is its Centering Pregnancy program which is funded through a one-time Blue Cross Blue Shield grant. Centering Pregnancy is a form of group prenatal care with small groups of 5-10 women who benefit from an extended visit with their OB-GYN.
The Centering Pregnancy group offers a bundled, comprehensive health visit including assessments, group learning, and social support. These groups create a therapeutic open exchange and discussion between the patients and provider.
Patients are grouped by trimester, so they bond as they go through their pregnancies. This forms a very safe space to ask questions and gain advice. “For patients, this is a no judgment zone,” says Dr. Green. “A lot of people don’t have anyone to talk to. This pregnancy group becomes like their surrogate family.”
Participating physicians are equally engaged. Dr. Green was recently told by one provider who is the Chair of Obstetrics at a local hospital, “Of all the things I do, this is really special. On the day I do Centering Pregnancy, patients get my complete focus, and I get their complete focus. I feel like I am making a difference.”
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Increasing Access to Maternal Care
As maternal mortality rates increase nationwide, one Detroit health center is employing several strategies to increase access to maternal care in their community. Read more in this recent NACHC blog post.
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The Name Game
Experiencing intense and overwhelming thoughts during your workday that you cannot get under control? Try the Name Game to help you curb spiraling thoughts and destress in three simple steps:
1) Look around you and name three things you can hear
2) Find two things you can see, and
3) One sensation that you feel
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© National Association of Community Health Centers. All rights reserved.
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