By Amy Balbierz, MPH

Childbirth is the number one reason for hospital admissions in the United States. Postpartum care offers a window of opportunity to impact the current and future health of underserved women. There are significant disparities in the receipt of postpartum care: approximately 60 percent of Medicaid insured women attend their postpartum visit whereas approximately 80 percent of commercially insured women go to their visit. Not only is this a “check-in” for mom’s current health status both physically and emotionally, but the postpartum visit is also a time to discuss long-term management for comorbid conditions (i.e. hypertension, diabetes, depression),  improve health prior to future pregnancies, and to link women  to  the primary health care system.   

The Icahn School of Medicine at Mount Sinai partnered with Healthfirst (a Medicaid managed care organization and the largest insurer of Medicaid deliveries at our institution) and a multidisciplinary team of experts in obstetrics, health economics, and disparities to design an intervention to improve care and reduce disparities in care for high-risk women. The payment system redesign included a cost-sharing arrangement between the health system and Healthfirst to cover the cost of case manager staff (social worker and care coordinator) and clinician education, and small financial incentives. Our methods are described in this post by Principal Investigator Elizabeth Howell, MD, MPP. After completion of this intervention, we’ve concluded that it had a significant effect on postpartum visit rates among enrolled Medicaid-eligible mothers at Mount Sinai. 

Here are the top 5 reasons why our RWJF-funded project, “Reducing disparities in care for high-risk postpartum women through redesign of payment and delivery systems” was successful:

1. This care delivery project integrates evidence-based techniques, including prior work at Mount Sinai. It prepares and educates women about physical and emotional symptoms of postpartum depression, gestational diabetes, and hypertension; bolsters social support and self-management; increases access to community resources; and reduces barriers to follow-up care. Our patient education materials, written in both English and Spanish, were simple and reinforced the importance of women’s health: “Remember, nearly all women will have some issue or problem after their delivery. Pregnancy and delivery demand a lot from you and your body. Go to your postpartum visit to check in on your health, to ask questions, to control issues, and to prevent issues from becoming problems.”
2. We pilot tested the research materials prior to the rollout of the intervention. Material was pilot tested with women who were attending their postpartum visit. The new moms were asked to provide their understanding of the patient education materials and feedback on how to improve them. The materials were updated based upon the postpartum mothers’ feedback and several of them stated they wished they had received this information during their own postpartum hospital stay.
3. The research team provided outreach to all clinical and non-clinical providers who come into contact with the patients, to ensure they knew about the who, what, why, and how of these reforms to the care delivery system. We also shared the specific aims of the intervention and stressed why it is important with staff at community health centers that provide obstetrics care. We met with everyone: obstetricians/gynecologists, maternal fetal medicine specialists, psychiatrists, nurse midwives, physician assistants, residents, postpartum nurses, lactation consultants, medical assistants, front desk staff, schedulers/registrars, obstetrics social workers, and administrative directors. We have found that staffs are very appreciative of this outreach because it acknowledges their critical roles in patient care. An informed and educated staff is much more likely to partner in the shared care delivery goals if they have a seat at the table. 
4. We developed a dedicated multidisciplinary team of frontline staff through consistent and ongoing training. The personnel conducting the intervention truly cared about reducing racial/ethnic disparities in maternal and neonatal outcomes. Weekly team meetings allowed staff to discuss and monitor the status of recruitment and retention efforts, intervention delivery (i.e., postpartum visit rates, home visits for high blood pressure, reminders for fasting glucose at the postpartum visit for mothers with gestational diabetes, and resources and follow-up for mothers with depressive symptoms), and patient outcomes. The entire team (OB/GYN, psychiatry, program manager, and care coordinator) could provide constructive feedback on the process and areas for improvement. These regular check-ins reinforced the importance of the delivery change process and helped staff feel more confident and address challenges.
5. We met patients where they were and provided continuity in care. New moms are busy. They have many competing demands, including but not limited to, juggling physical and emotional postpartum symptoms with caring for their newborn, other children and adult family members. They are often trying to do all of this while struggling with sleep deprivation, transportation challenges, and unstable home or work environments. For these reasons, the study had multiple touchpoints with postpartum women: during the hospital stay, a two-week follow-up call, a three-week survey call for data collection to assess various postpartum issues (i.e. physical and emotional symptoms, self-confidence/management skills, social support, etc.), postpartum visit reminder calls, and another survey at six-months. The team was sensitive to the patients’ time and energy constraints by providing options to complete the survey by phone at a time convenient to them, email, self-addressed stamped envelope, or in-person at their postpartum visits. In addition, the team care coordinator tried to meet in-person with new mothers who received their care at the hospital clinic. This familiar face and continuity built trust and patient engagement amongst a group of high-risk postpartum women. 

In sum, there is much good to be done by implementing a patient-focused program of health care starting at the mother’s hospital stay for delivery. This is a window of opportunity that should not be missed, in order to set families on a positive course of health from baby’s day one.