CyncHealth, Collective Medical and Innsena are being recognized by the Department of Health and Human Services' Racial Equity in Postpartum Care Challenge, including federal funding of $40,000, for their postpartum care program in Omaha.

Pregnancy-related deaths are three to four times more common among minorities than among Caucasian women, even among those with a college degree. This program improves postpartum care for Black and Indigenous parents and children with high-risk conditions who participate in Medicaid and the Children's Health Insurance Program, and significantly reduces maternal and neonatal mortality.

Out of the 25 winners recognized by HHS, this program is the only one using health information exchange technology to improve personalized care at the community level.

THE PROBLEM

"Support throughout pregnancy and postpartum is critical for creating lifelong health and wellbeing, physically and mentally, for mother and infant," said Jaime Bland, CEO of CyncHealth, the HIE. "In the days, weeks and months following childbirth, women are in a critical time for their care as they experience physical, social and psychological changes.

"Thousands of women experience unintended outcomes of labor and delivery that result in significant short- or long-term consequences to their health," she added.

Postpartum care visits in the weeks following a birth are essential, because this is when a woman is most at risk for complications that can be quite serious, even fatal. Pregnancy-related mortality for Black or African American Women and American Indian and Alaska Native women is two to three times higher than for those who are white, Hispanic and Asian/Pacific Islander.

While ample services exist for postpartum care, women continue to face barriers to receiving that care.

"In Nebraska, 19% of women reported sometimes feeling down, depressed or hopeless after their baby's birth, and over 7% reported feeling that way often," Bland said. "National statistics say one woman out of four experiences depression after the birth of a baby, but only one woman out of eight asks for help with that depression.

"Notably, Nebraska ranks 19th nationwide in maternal morbidity and faces significant racial disparity in maternal morbidity and mortality," she continued. "In Douglas County, Black infant mortality rate is 14.5 in every 1,000 births, which is more than double the rate of white and Hispanic infant mortality."

PROPOSAL

CyncHealth is the designated health information exchange for Nebraska and Iowa, and serves more than six million people across the region.

As a trusted neutral convener of health information, CyncHealth is building a health data utility in which health data follows a person wherever they seek care and offers alerts on emergency department visits to primary care providers and builds a longitudinal health record that gives providers insight into each point of care a patient is receiving.

"This kind of holistic patient data offers a unique solution for closing gaps in maternal health needs," Bland explained. "When timely alerts, medication history, encounter information, care plans and other needed information are automatically shared, transitions of care are a better experience for people, outcomes improve, redundancies are reduced, and – most important – mothers and infants are less likely to fall through the cracks of the healthcare system and are more likely to receive the care they need and deserve."

CyncHealth partnered with two other organizations – Innsena, a health technology consultancy, and Collective Medical, a PointClickCare company that creates and delivers notifications at the point of care – to design the technology that helps healthcare providers and care teams identify at-risk mothers and infants to enable improved and informed care coordination before, during and after delivery.

These notifications alert healthcare providers in real time and at the point of care. Such notifications inform providers of pertinent diagnoses, conditions and recent health events that support clinical decision-making.

"This results in earlier and timely interventions, reducing dangerous complications and overall cost of healthcare," Bland said. "Innsena is a consultant to both companies, ensuring successful program implementations and support for policy changes, which are sometimes necessary.

"Using CyncHealth and its technology partners to close maternal health gaps also provides an opportunity to measure the success of different interventions," she noted. "Leveraging technologies and partnerships that facilitate the availability of key indicators such as key preventative care measures, coordination for transitions of care, and avoidable condition complications, offers critical insight into the effectiveness of programs, initiatives and interventions."

Showing program success with tangible numbers increases the odds of sustaining and growing program budgets through grants, donations, other awards or internal sources to secure the long-term success of improving maternal and infant health disparities, she added.

MEETING THE CHALLENGE

The maternal health program supports healthy outcomes throughout the pregnancy and postpartum journey by helping healthcare teams identify at-risk mothers and infants in order to enable improved and informed care coordination before, during and after delivery, specifically Black, African American, American Indian and Alaska Native parents with high-risk conditions who participate in Medicaid and the Children's Health Insurance Program.

"These populations were chosen because they are at significantly higher risk for maternal morbidity and mortality compared to other races," Bland explained. "Notably, these racial disparities occur regardless of education or socioeconomic status. And maternity health is a significant issue: Approximately two out of every three pregnancy-related deaths are considered preventable.

"The program assists with identifying pregnant women with high-risk conditions such as diabetes, hypertension, depressions and/or anxiety, and substance use disorder, and substance-exposed infants, and makes key data points available that inform evidence-based approaches aimed at increasing access to and attendance at healthcare visits and quality of care throughout pregnancy and postpartum," she continued.

Collective leverages ICD-10 diagnosis codes and ontology (value sets) drawn from hospital Admit, Discharge, Transfer data and, potentially, patient panel files from OB/GYN, PCP and FQHC clinics, and generates high-risk pregnancy and postpartum flags that trigger real-time alerting, cohorts and reports – depending on the workflow and use cases of managed care organizations, hospitals, clinics and other care settings.

Flags can also be added through a patient eligibility file by a managed care organization or clinic that include Medicaid or CHIP status. CyncHealth worked with Collective Medical to expand the program to include race/ethnicity reporting so that participants with this program could apply filters and identify women who are Black or African American, and American Indian and Alaska Native.

"By using critical system, clinical and community strategies that address gaps in caring for Black, African American, American Indian and Alaska Native care, outcomes and conditions that are typically associated with lacking health services and support are prevented," Bland said.

"Additionally, users of the Collective technology can add specific patient care insights that surface key information for a woman's care team," she continued. "Finally, Collective also pulls in contact information for care team members for improved care coordination across disparate providers."

RESULTS

The Omaha program was recently recognized by the U.S. Department of Health and Human Services as a Top 25 winner in Phase I of its HHS Racial Equity in Postpartum Care Challenge. The program is also planning to enroll in Phase II of the challenge, which will measure outcomes and success.

The Maternal Health program through CyncHealth enables hospitals, clinics, federally qualified health centers, PCP clinics, OBGYNs, and potentially substance use disorder clinics and Medication Assisted Treatment facilities to identify mothers and infants in need of care and to facilitate and support holistic coordination of their care throughout the pregnancy and postpartum experience.

"Collective Medical has run variants of this program in both Washington and Idaho, where they had great success," Bland said. "For instance, in Washington, one analysis found that pregnant patients participating in the program had a 54.6% decrease in ED utilization. The Omaha program is still in its early stages and is waiting on more numbers to provide good metrics."

ADVICE FOR OTHERS

"Move to a value-based model, invest in medical records technology and integration, and you'll realize tremendous success both in terms of internal efficiencies and patient outcomes," Bland advised.

Bland stresses that:

• SDOH matter. The field of addressing social determinants of health is a tremendously important field, she said.

• Technology that works is here. Advanced data infrastructures exist in healthcare today that are addressing SDOH disparities via a business model based on value-based care, she noted.

• Other states can replicate this success. As noted, the Omaha program is happy to share methods and best practices.

"SDOH are the economic and social conditions that influence individual and group differences in health status, and they can be a major cause of health inequities when populations do not have access to the same resources," Bland said.

"The field was virtually unexplored a generation ago," she continued. "Recognizing the potential for impact, the government allotted more than $650 million in 2022 to support various Medicaid pilot programs to address SDOH issues."

The Omaha work was specifically on maternal health, an area the U.S. Department of Health and Human Services announced $350 million in awards to address. Many states are using these funds to expand home visiting services to families most in need, increase access to doulas, address health outcome disparities, and improve data reporting on maternal and neonatal health.

"If you're not one of those states, learn about those of us who have working programs, and get to work implementing and succeeding in your own region," she concluded.

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