Making inroads with maternal health equity

Good morning everyone. Thank you for joining us here and have a really interesting and timely topic that we want to get into here this morning. And I really appreciate you being here with us. I'm Scott Dunn, I'm with Optum. And it's my pleasure this morning to introduce our distinguished panel that we have here to talk about the issues surrounding maternal health and some of the issues and challenges that we all, as a country and as our jurisdictions are facing as well. And so I want to get right into it here. Just a couple of things. Of course, we all thought, let's try and silence vibrate off, whatever with our phones and other devices. And if we could just hold the questions until the end so we can allow Mei Lin and Karen to get through. And then we'll be looking forward to your questions that you have here and if you can speak into the mic. We are recording here, so that would be helpful too and would appreciate that. With us here this morning, we have Karen McEwan who is the My Healthy Baby project director for the state of Indiana and previously served as the state health officer for the state of Wisconsin. And she is also an author and has a lot of expertise that she brings home as well. Who is sharing? With us here at Optum and Karen on that. So in case anybody has any issues, we are well equipped to address anything that comes up. So I look forward to that. With that, we will go through some overview of what is kind of going on from a national perspective in terms of maternal health issues. And then we'll take a look specifically at what's going on in Indiana and Washington, D.C., and some of the initiatives that are underway here. So without further ado, let me have my Lynne kick us off.

Sure. Could you switch flip to the next slide?

You bet. Great.

Great. There we go. Good morning, everyone, and thank you for being here with us today. I have the opportunity to talk about this topic that's very near and dear to my heart. And I say any day that I get to talk about maternal health and infant health and health equity is a really good day. So I appreciate you being here. While we recognize the US is a global leader in innovation, it's a distressing. Really. How? Poor performance we have in the area of maternal and infant health and health disparities. I mean, we see that in the the outcomes of states and the state disparities that we see for maternal mortality and morbidity. The US has three times the infant mortality rate of most high income countries. And then when you think about mental health when in, when individuals are in this course, I think providers, they don't think about mental health as much as they should in the course of pregnancy. And so we've seen that impact around mental health, with a 16% increase in mental distress for birthing individuals and an increase in drug deaths for women as well. Recent years as similar to what we've seen in our rural hospitals. There's an increased number of obstetric units and birthing units that are closing. According to the March of Dimes, there was a decline of 1000 birthing centers between 2019 and 2022.

Then, as we turn our attention to infant care, the disparities are just as pronounced there, with black infants 2.4 times likely more likely to die as white infants. And those root causes we know are tied to poverty, limited access to prenatal and primary care. Those are the things that are some of the drivers of this infant mortality rate. It's, in my mind, undeniable and unacceptable are maternal mortality Disparities that we have. We know that for Hispanic women, that rate rose over 100%, almost 120%, and for black women, 57% higher in the years of 2019 to 2021. Additionally, we cannot overlook the limited access to services with women in the U.S. of childbearing age. 6.9 million women live in counties with low or no access to maternity care. Nor can we ignore that over 25% of live births occur where the mother did not receive adequate prenatal care. So we acknowledge that these are not just disparities. They're injustices within our health care system. And as a community we can address these. And I'm really excited about the the implementation of strategies that I'm seeing across the country and the ones that we're going to talk about today. So with that, I'm going to turn it over to Karen to talk about what's happening in Indiana.

Thanks, Marilyn, and thank you all for being here. I am also excited to talk about the work we are doing, and I'm going to start with a short video.

I'm a first time mom. I have one child with my fiance. I was pregnant when I first met Jen. Our first meeting she knocked on the door. She asked me how far along I was and I was six weeks. It was great because I got to start from day one as far as the education. When you are pregnant and you know you're exhausted, some things you you forget. So I needed the support from Jen to help me as a parent with Desiree.

I noticed the signs of some postpartum depression.

With the help of Jennifer, we were able to do some postpartum depression screening.

Nobody will tell you how they're feeling mentally if they do not trust you or feel comfortable with you.

My daughter was a virgin. She she did not walk for me.

I came in and Dua was standing up and I said, is she walking yet? And I sat down. I was like, come here to.

Being able to breastfeed was huge for me and I was confident that my baby was eating. She was well fed. No being in the program. I've learned so much about myself and my daughter. I have a sense of security and confidence that no one can take away from me.

Our world needs better people, and in order to be better people, we also need to be better parents.

I would say that it's better to join and not need the services than to never call at all. With the education that I received, the support, I felt like a dang good mom.

I'm just going to just a second here.

I'm a first time mom. I have one child with my.

So my healthy baby was created to connect pregnant women in the state of Indiana to home visiting programs like the one you saw described in that video. The underlying impetus for our program was actually the infant mortality rate. Hold on a second. I'm getting your computer's about to restart, so I'm just going to say snooze. The the infant mortality rate in Indiana. And I've got the slide here. Infant mortality is measured as how many babies die during their first year of life. For every 1000 babies that are born. And calculating that rate allows us to compare infant mortality across locations, across groups. In this graphic, you can see that in Indiana in 17, we had the highest infant mortality in the Midwest, and that had been true for many years. I, we I'm showing the 2017 data because there's always a lag, and these are the data that people were looking at when they developed the concept of my healthy baby. Beyond looking across states, as I said, we can look across groups. And in Indiana in 2017, there were 5.9 babies who died for every 1000 live births in the white population. In the Hispanic population, it was 7.6, and in the black population it was 15.3. So we wanted to address infant mortality for the state as a whole. And we also wanted to eliminate these disparities. That was the that was the goal or the motivation. Basically, we wanted more families to be able to celebrate their baby's first birthdays. I'm going to talk a little bit about maternal mortality.

That wasn't the primary reason that my healthy baby was established, but from the beginning, the people who were working on it also hoped that we would make a difference here. And so you can see on the left the graphic from 2018 to 2021, these are the states infant mortality or maternal mortality numbers. And the national on the right, you can see the numbers that have been reviewed and carefully developed by the Maternal Mortality Committee in Indiana. The numbers are lower because they go in and look at every death certificate. They link back to birth records. They find some infant mortality. I'm saying infant, some maternal mortality cases that were not indicated on a death record. And they find some that were indicated on a death record that were not actually maternal mortality. So they are very confident in these numbers. They did just release their most recent report. And in 2021, I'm happy to say it dropped back down to 17.5. I say I'm happy. That's still too many. And we're continuing to work on this as well. The vision of my healthy baby is for every pregnant woman in Indiana to have access to personalized guidance and support, like you saw in that video during and beyond her pregnancy. We couldn't actually do everyone right at the beginning. So we started at the beginning of 2020. In high risk counties for women insured by Medicaid. And at this point, we are we are active statewide for women insured by Medicaid.

And if somebody who's not insured by Medicaid finds out about us and contacts us, we will also work with them to connect them. Our goal is to connect more women earlier in pregnancy to these services and to try to give the programs more opportunity to have an impact. My healthy baby had tremendous support. The enabling legislation was unanimously passed after being proposed by the governor for both parties. Both houses. Nobody was nobody opposed it. And it had been the it was the brainchild of three agency heads the Indiana Department of Health, Family and Social Services Administration, where Medicaid is housed, and the Department of Child Services, which happened to be headed by an obstetrician gynecologist, a pediatric ER doctor and a pediatric nurse. And then there has been very strong interagency collaboration among those three agencies throughout our development. Our funding, that initial legislation gave us $3.3 million a year in state funding. And then, thanks to the collaboration with the Medicaid agency, a lot of the work we do, since we're focusing especially on women insured by Medicaid, is eligible for 50 over 50 match at Medicaid admin. And we also have some enhanced funding, thanks to our team at Medicaid where for development, especially in the IT and data spaces, we can get 90 over ten matching and then 75 over 25 for maintenance and operations. Our basic process is our typical process is that the Medicaid agency looks in their data sets to identify pregnant women.

They then transfer data over to the Indiana Department of Health, where we have a team of specialists who reach out mostly by phone to the women, and if they get in touch with them, if they're able to reach them, they have a conversation and offer a connection to Daniel Stewart. If the woman accepts, we make a referral by sending her information to the program so that they will then outreach and provide services. There is also an opportunity for women to self-refer if they see an advertisement. We have a pretty strong marketing campaign, or to be referred by a provider or somebody in the community. And I never give this talk without emphasizing we are building the referral system. The home visiting programs already existed. So again, we're trying to connect more women earlier in pregnancy to these services. Digging a little deeper into the steps of that process, on the early identification side, 89% of our potential clients that we try to contact actually start in the come to us from the Medicaid data sets. Specifically, we get information from everybody who has been approved for presumptive eligibility for pregnant women. That is, you're not you don't have any insurance. You go to your provider. They do a really quick process to see if you might be eligible. And if it looks like you will be, you can get covered with for your pregnancy related expenses while you complete the full Medicaid application. So if that happens, we get your information. If you apply for Medicaid and indicate that you're pregnant, we're going to get your information.

If you're already insured by Medicaid and your status changes to pregnant, which can happen in a multitude of ways, we're going to get your information. And if you're already insured by Medicaid and you have a clinical outcome data in the in the health information exchange, we will also get your information. So if there's a pregnancy test or an ultrasound in that system, then every day Medicaid transfers to the Department of Health the data so that we can reach out as quickly as possible. I am not going to go over this flowchart, so it's okay. I put this on here to show that it's very complicated. You'll get the slides later I believe. So if you want to dig into it you can. But each of these rows is one of those data sets that I just said. And we had to work with the data teams and the contractors over at FSA to figure out how to pull each of these. And for some of them, they actually reworked their own data flows internally to make sure that the data, the data would hit sooner into the databases than it would otherwise have happened. For example, if somebody applies and for Medicaid and indicates they're pregnant, we do not want to wait until that's approved and loaded into the data system. We want to know right away. So the day after they submit that application, and even if it's incomplete, if it has the key points that we need, we're going to get the information.

And we originally originally all of these data sets were just uploaded updated weekly. We wanted more. More frequent for a couple of reasons. We want to reach them as early as possible, and a week in pregnancy is quite a long time. And also these phone numbers don't last that long. Sometimes somebody's phone number works today and it doesn't work in a week. And so the sooner we can get it and access it, the more likely we are to be able to reach them. For on the coordinated intake side, once the Indiana Department of Health gets the information, they conduct a brief screen. We don't ask a whole lot of questions. We do not do a full social determinants of health screen, because if we make a referral, they're going to do a full screen, and we don't want to keep asking the same questions. We're also really aware that we are cold calling people. They did not expect this call. They could be with family and friends. They could be in the grocery store. So we're not asking questions about substance use disorder, intimate partner violence, anything that would be really awkward in a in a call like that. And then if they accept a referral, we make a decision of where to send them based on their eligibility, best fit and the capacity of local programs. And I'll talk a little bit more about that in a minute. The home visiting programs we refer to fall into a variety of categories.

We we sort of break them down mentally into two groups. A lot of them follow a a national model healthy families, nurse, family partnership, parents as teachers. There are also some programs that were developed in Indiana for specific community needs. So we did develop some state standards that the national models are able to fit into, but also help define for the local models. And anybody who's able to affirm that they meet those standards can join the My Healthy Baby Referral Network. For the referral algorithms, we worked closely with our local partners, the home visiting programs in every single county individually to figure out what the algorithm in that county should be. There was a lot of distrust of us right at the beginning, thinking we're going to mess up our lives, and you're going to take our referrals and send them somewhere else. And by having these meetings, a series of meetings before we went live in any county, we really helped to build that trust. And the algorithms could be as simple as if a county only has one program, we send all the referrals there, or if they have only two programs, then maybe the one that has the tighter eligibility criteria gets their clients, and then everybody else goes to the other program. Sometimes when that happened, we also had to promise to go back and make sure that the split was not uneven and promise we would modify.

And we did. We met with every county again afterwards and said, here's how things are going. Is that working for you? And sometimes it was really complex. So we have one county that has about eight different programs. And here you can see the algorithm for them. If the mom is below 28 weeks you would send them to here except for some exceptions. And after 28 weeks you would send them here. But and if they were more than 110% of FPL, then you would send them here. And the exceptions are if they're younger than 18, you would send them to these other programs, or if they have a history of a miscarriage, you would send them here. I show you this because we had to build into our IT systems the ability to support very complicated algorithms as we were talking to the clients. And if they said yes. We have made some modifications over time. When we started out, and for quite a long time when we sent a referral to a program, we sent it by secure email. So our communication specialist would type the information in, make sure it was secure and send it off, which also meant we didn't know for sure if they got it. We didn't know if they were doing anything with it. We recently we, I guess almost a year ago now launched our closed loop referral system so that we now our system as soon as the communications specialist indicates in the system that they're sending a referral, then the program gets an email to log in to our system.

They see all the client's information and they can indicate right then that they are accepting the referral or declining the referral. That now gives us the ability to refer if they're declining for any reason, so that the mom doesn't just get lost. And we are also able to track and make sure they've responded. If they do not respond within a week, we send them a reminder. If they don't respond after two weeks, we pull it back and send it somewhere else. We are working with all of these programs to get data back. We really want to know what happens after we send the referral. And so we've got data sharing agreements now in place with programs that receive 95% of our referrals. We're working with the remaining 5%, and we're working to build portals to allow them to send the data back. Because each of these are individual programs, they collect it in different ways in different systems. And so all of the work of transformation and standardization is underway as well. And then another thing we're working on is automated emails, so that moms in various points of the process can hear, hear from us if they've said, not right now, but I might be interested in the future, then they can get some emails. If they've accepted a referral, they can get an email. This is our basic data flow process picture. So starting at the beginning we have the data.

In other systems. We're about to actually start working with Wick as well. So Medicaid Wick comes over to our local database at the Indiana Department of Health. From the local database. It's loaded loaded into the coordinated intake and referral system where the communication specialist, that's where they work. That's where they document their interactions. If the client accepts a referral, there's that provider portal that I just mentioned every day. We also take data out of the coordinated intake referral system back into the local database so that as we're loading, we can check for duplicates and not just keep calling the same people. If if Medicaid happens to send them over more than once. Then you see the home visiting provider databases all three is way inadequate. It's just you couldn't fit them all on here. But there are a lot of different databases that will be loading information into our provider portal from our local database will move data up into the cloud, where we can compare with vital records, data and other state data sets. So what are our outcomes? It's too soon yet to see outcomes in, for instance, birth outcomes or infant mortality. But what we know is that for every ten white moms that we try to call, one ends up accepting a referral. And I will tell you, the biggest gap here is just being able to reach people. When you think about that, it might actually be surprising that we reach that many, because I don't answer the phone when a strange number comes up.

For black moms, though, it's twice that many. Two out of every ten answered the phone and agree to a referral. And if we get to talk to them, over half accept a referral. And for the Hispanic moms, it's actually 25% or 1 in 4 that answer the phone and say, yes, we will. We will accept a referral. Obviously, our major efforts right now are to reduce the number in gray and increase the number in teal. And because we focus on that so much, it can be easy to lose sight of what we have accomplished. So since we started with one county in January of 2020, till today we've had more than 40,000 conversations with women. That's people who have answered the phone and talked with us. And even if they didn't accept a referral to home visiting, we also offer them access to other resources. So we're not going to let them off the phone before saying without saying, is there anything else we can help you with? We can help them with Medicaid applications, finding prenatal care, finding housing. Our team has access to the full 211 database. So anything that's in there we are able to help with as well. We've made over 18,000 referrals to home visiting programs, and our estimate is that about 4800 of those have actually gone on to enroll and receive the kind of support that you saw Desiree describe. So that's our program, and I'll look forward to your questions at the end. All right.

Thanks, Karen. That was great. I have the opportunity to talk to you about the work that we've been doing in Washington, DC. And if you were here in 2022, we were just launching this work, and I was able to be on the stage and talk about that. We referred to it as the DC Maternal Health Project. But today I'm really happy to tell you about the honey program. So why DC? You've heard the statistics. And truly, in Washington DC there is a crisis. The maternal mortality rate in Washington, DC is 35% higher than the national average, while black pregnant women constitute only half of the births, they make up over 90% of all pregnancy related deaths In 2021. We started with our data analysis, and we used our both public and proprietary data sets and analytic tools to really take a deep dive into what are the social drivers impacting birthing individuals in Washington, DC? We knew we wanted to focus in on maternal health. We knew we wanted to do work in Washington, DC. What were the things that really were going to make a difference? So when you look at this map, you'll see the preponderance of pregnancy associated deaths are in those southeast areas of Ward seven and Ward eight. We knew that from the data that there were over 1200 pregnant women in Washington, DC seeking housing services, and that those women had a higher rate of developing hypertension as well as other chronic illnesses.

So the data led us to this path. In addition, we did a series of stakeholder interviews and really tried to understand what was happening in the community understand what work had been done to date so that we didn't duplicate those efforts so that we amplified the messages. And in order for us to do that, we formed a community equity collaborative. And that Community Equity Collaborative was made up of stakeholders in the Washington, DC area, from human services to federally qualified health centers to internal and external partners like Mcos. So with those interviews, we and community benefit community based organizations for sure. From those interviews, our data analysis, we narrowed down the area that we needed to focus in on to four areas. One timely entry into prenatal care. There is points of bias in individuals accessing care within the health care system in Washington, D.C.. There was still and is a definite shortage of housing and individuals that are experiencing homelessness, as well as the need to educate birthing individuals about alternative methods of care during their pregnancy, especially use of doulas. So with that Community Equity Collaborative, we were able to focus in on the area that needed the most attention for for that area. And that was really the area of homelessness and perinatal care.

So our stakeholders gave us that guidance. We embarked upon a journey, and that journey led us to the honey program. So the individuals that are part of the honey program, which is housing our newborns, empowering you, that's honey. The individuals that are are birthing individuals experiencing homelessness present themselves to the Family Services Center called Virginia Williams. And that's a central intake center for individuals that are experiencing homelessness. The honey perinatal care coordinators and navigators are housed in the central intake unit. So they're there on site, on prem coordinating and being a part of the team of of people that are providing that type of support for individuals, the perinatal care coordinators. They do navigation. They provide that wraparound support services. And when we talk about the importance of a home visiting program. Definitely great outcomes. Very important. But I think it assumes that you have a home. So we're working with Human Services to ensure that those individuals that are pregnant or have just recently had a baby are able to find housing support. So those are the things that were really the key and core focus areas for the honey program. The timeline that we progressed on, we started in 2021 to make sure that we understood the the problems and the nuances, looking at the data, doing those stakeholder interviews. Then we moved into that design and then the actual implementation of this program.

So in 2023, in May, the UnitedHealth Group Foundation funded one of the first perinatal housing navigators. With that, the federally qualified health center that we're working with called community of Hope. They also applied for HRSa grant and were awarded a $2 million over two years to support this program. The program launched in October of 2023. And then in that time, they also had applied for a foundation award from Jeff Bezos Day one fund. And they did receive that for $3.7 million. The key part of this component is the funding that they received makes this program sustainable. So I heard this morning in the keynote that no one wants to go to work for the Department of Health. If it's grant funded and it's going to run out in two years. And what am I going to do? So now, this program, the honey program, has that sustainable funding to support the program to meet the needs of the community. Right now there's 11 people that are focused in on this program. So I'm really proud of the work that that they've accomplished over the the course of the time that we've been working with them. This is a little bit of an eye chart, but I want to just call out some of the things that were important to us as we were helping establish this program was the community impact and the community impact multiplying and growing as we've continued to work with with this organization.

The learning impact. So not only are we kind of learning and evolving, and I heard Karen talk about the modifications of the program that's happening with this program as well. And the learnings aren't sustained with community of Hope that Federally qualified Health Center. They're being ingested by the Department of Human Services, as well as the stories being told to mcos in the area, because that's really what we're looking for from a broader, scalable situation, is to take this learning this pilot and make it more wide scale, not only in Washington, DC, but in other communities where individuals are experiencing homelessness and are birthing. So this program, the the Honey Navigator program, at the very beginning, we thought about what are we going to measure? How are we going to know we made a difference? How are we going to know that we were successful? And at the beginning we're helping from an analytics standpoint, bring that activity tracking that they are doing right now as part of their work. They have a goal to impact 400 clients this year. And as of end of February, they had 55 referrals. And those referrals are coming in from the housing authority, where they sit with Human services as well as other homeless programs in that DC area, that they are getting referrals and impact, as well as the community of Hope.

Has made outreaches to hospitals to let them know that they're there for assistance and support for for the patients. So we're we're looking at prenatal care appointments postpartum appointments. So that linkage back to Crisp or the Hie, the federally Qualified Health Center is able to track some of those outcomes to know, did they show up for their postpartum visit? What is it looking like from an outcomes perspective? All along both from, you know, their design, our design with them, Satisfaction was also at the key. And with that, as the program has evolved, they are in the process of setting up their own advisory council with individuals that have this lived experience, individuals that have gone through this program or gone through similar programs so they know that they can meet the needs of the clients that they're trying to serve along the way. We talked about that learning in the community and making sure that we provide education not only to within that community, of the community of Hope, that federally qualified Health Center, but back out into those birthing centers, the hospitals in the area where individuals are having having their their births. So really excited about the progression of this project and the work that's happening in Washington, DC.