THE FOUR PILLARS
Underserved population groups deserve focused care that combines what we call our “Four Pillars”. Commuinity Care Connection health equity interventions based on the Community-Based Health Equity Model and our Four Pillars, will significantly improve maternal and infant health outcomes by empowering expectant mothers to play a more active, better informed role in their pregnancy care.
Lack of access to equitable and respectful maternal care is at crisis levels in the United States and elsewhere. We work with H.E.R. and its Health Equity Partners to implement interventions designed to improve maternal care by giving expectant mothers autonomous access to perinatal and postpartum services, education and supportive services needed for healthy pregnancies and birth outcomes. Connected care is provided via the H.E.R. Health Equity Platform, the H.E.R. Maternal Care App, and our Community Care Kits containing a BP cuff, thermometer, a weight scale, a heart, SPO2 and sleep monitoring device, and glucose monitor as needed. The Four Pillars form the bedrock of a program meticulously crafted to not only address the immediate healthcare needs of expectant mothers, but also foster enduring relationships built on mutual respect and understanding.
True, Ongoing Trust – The key to any successful maternal health intervention is trust. Without it, outreach programs will continue to fail, whether well-funded or not. We intend to build trust by partnering with community and faith-based organizations and leaders, including block captains, who are community-based, who reflect the culture, values, preferences and lived experiences of the expectant mothers we intend to serve, in order to (i) identify and address root causes of maternal and infant care disparities in the community, (ii) co-create with underserved communities to implement community-based solutions, and (iii) define and measure program success from their perspective. Trust building also requires active listening and engagement in the communities where underserved mothers reside, which we intend to accomplish through root cause analysis, surveys, focus groups, workshops, and community meetings, led by culturally aware nurse-leaders, community health workers and doulas who serve as bridges between expectant mothers and the health care system, and who will support them during pregnancy, labor and postpartum up to one-year after delivery. Community-centered approaches to maternal care can ensure that pregnant women get care where they are most comfortable, including virtually in their homes. Programs that anchor the support and care people receive within their community during pregnancy have been shown to improve a variety of birth outcomes and may also reduce maternal mortality.
24/7 Ease of Access – Improved access to care is essential for health equity. Expectant mothers will have 24/7 access to caring health professionals and RN/Doulas via the H.E.R. Maternal Care Platform powered by GTS, a remote patient monitoring platform that enables healthcare teams to monitor an expectant mother’s vitals (blood pressure, blood glucose, sleep, weight, Sp02, heart rate variability, and body temperature), as well as communicate with her via video conferencing using HIPAA compliant video. The platform readily integrates with any Bluetooth, USB, Wi-Fi, or Cloud-based medical device, as well as with any EMR platform, providing ease of use for end users.
Elevating Health Literacy, Engagement and Advocacy – EE&A is made possible through the H.E.R. Maternal Care App to improve participants health literacy, fundamental to achieving health equity, and to facilitate advocacy, essential to addressing health care disparities. Upon opening the App on a smartphone or tablet expectant mothers will enter their personalized maternal CareOrbit putting at their fingertips links to the resources they need for healthy pregnancy outcomes. The App with CareOrbit education, engagement and links to supportive services that address social determinants of health, creates a deeply-engaging HIPAA-compliant learning environment for expectant mothers by applying best practices from the engagement industry to create proprietary Storytelling Blueprints that map all key content to directly drive targeted health literacy and positive actions important to maternal and infant health outcomes. The CareOrbit can be accessed on any screen (smartphone, tablet or desktop) and does not require special training or downloads to track individual usage to help ensure active engagement with key information.
Care Coordination of Supportive Services – Care coordination is be made possible through the App, which provides links to supportive services that address SDoH, including referrals to housing and mental health resources, and access to transportation, housing, healthy food and nutrition programs (with an emphasis on improving access to programs such as WIC and “Food-is-Medicine”), and other services that address SDoH—factors such as socio-economic status, education, neighborhood and physical environment, employment, social support networks, and access to health care, that influence health outcomes.
The Nurse Monitoring Regimen
After onboarding and connecting with their nurse-doula monitors, mothers will be issued a Community Care Kit, which includes devices to monitor BP, sleep, heart rate and SPO2, as well as glucose meters, thermometers, and Wi-Fi enabled weight scales. Data from readings can be transferred directly to the mother’s medical record for providers to review and monitor to speed provider intervention when needed. Expectant mothers can track their condition at particular times of day or even multiple times per day to and correlations with eating certain foods, exercise, or other variables.
Each Nurse-Doula monitor will be equipped with an iPad to monitor all metrics and data that the expectant mother provides through Patient-Generated Health Data maintained on the CCC/GTS dashboard. Each day monitors will log into the portal to monitor a panel of mothers’ vital signs and to answer surveys designed for specific pregnancy-related issues. If a would-be mother’s vitals fall outside pre-configured parameters, a real time trigger response will follow. A nurse monitor may intervene via video, secure message, or coordinate a virtual visit from one of our doulas. If abnormal readings persist the mother’s care provider will be notified. For mothers who elect not to be monitored by CCC, data from their readings can be transferred directly to their medical record for their preferred providers to review and speed provider intervention when needed. Mothers, infants and their providers will benefit from our comprehensive virtual care program that complements traditional care.
Our Specific Goals
- Increase the proportion of pregnant women who receive early and adequate prenatal care
- Decrease the number of low and very low birth weight among program participants
- Decrease the number of pre-term births (< 37 weeks) among the mothers we serve
- Decrease the overall incidence of infant mortality
- Decrease health care system costs associated with maternal and infant care while significantly improving expectant mothers’ experiences of care during pregnancy and one-year there after
Our General Goals
- Promote respectful maternal care
- Decrease barriers to care
- Address key health literacy needs
- Decrease complications
- Decrease stigma
- Improve Maternal Care Advocacy
- Decrease staff load with calls to clinic
- Decrease patient anxiety and confusion
- Address complexities in ways patients can relate to
- Connect expecting and new moms with resources to support their immediate socioeconomic needs
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