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New York

About the Team

The New York team is comprised of:

The team is piloting its initiative to advance perinatal health equity for cisgender, pregnant women who are covered by Medicaid at Sun River Health clinics in New York. The pilot includes a blood pressure remote patient monitoring (RPM) program for pregnant women in their third trimester at three different Sun River Health Federally Qualified Health Centers. The team is in the early stages of designing a payment model that will sustain the RPM and the various screenings and services provided by the program.

Identifying and Diagnosing the Problem

The New York team reviewed Sun River Health’s root cause analyses of inequities in a variety of key Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. Root cause analyses were completed by a cross section of frontline providers and staff to better understand why identified inequities persist and to design interventions to reduce or eliminate inequities. The team decided on maternal health because it is a national priority. Sun River Health has strong, existing maternal health programming.

Designing and Implementing Change

The team’s care transformation has three main components:

  1. Remote blood pressure monitoring for pregnant women in their third trimester to postpartum to address preeclampsia and pregnancy-related hypertension.
  2. A virtual, transition of care visit from a nurse practitioner within 48 hours post-discharge that includes a postpartum depression screening and referral to a behavioral health provider if necessary.
  3. A social drivers of health (SDOH) screening delivered during patient enrollment and transition of care visit.

The team’s initiative began in October 2023. The pilot will continue for six months before final evaluation and possible scaling to other clinical sites across the Sun River system. The team is collecting data on numerous process and perinatal health outcome metrics to guide more focused initiatives in the future. The Sun River informatics team will analyze the data with an equity lens to determine if disparities in health and healthcare outcomes have been reduced between white patients and Black, Latine, and Indigenous patients, respectively.

Partnering with Patients, Members, and Communities

Sun River Health will be holding two race-specific focus groups for individuals who participated in the pilot: one for Indigenous women and the other for Black women to learn more about their experiences with the program and identify areas for future improvement. Additionally, the team is working with community partners who provide social needs services to improve the inter-organization referral process when health-related social needs are identified for a patient through the initiative’s SDOH screening.

Looking Ahead

The team hopes to use the pilot as a starting point to devise a general strategy for care model dissemination and translation that can be scaled throughout the Sun River Health system. The team also is developing a plan for fiscal sustainability of the pilot program and exploring value-based payment mechanisms to support health equity interventions.