Using Telehealth Check-Ins to Improve Maternal-Child Health Outcomes
How virtual visits will help NewYork-Presbyterian spot and address risk factors that could affect maternal health and early childhood development.
With pregnancy comes a lot of doctor appointments. Regular and frequent prenatal, postpartum and well-baby visits help to ensure healthy mothers and babies. But attending all these in-person appointments can be difficult, especially for women challenged by social determinants of health, such as a lack of transportation or social support.
Thanks to a $100,000 Innovation Challenge first-place award from the American Hospital Association, NewYork-Presbyterian, in New York City, will be piloting telehealth visits with at-risk mothers. The goal is to make it easier for expectant and new mothers struggling with social determinants of health and other issues to connect with their providers and get needed care, services and support. The Innovation Challenge is exclusively sponsored by First American Healthcare Finance.
"It's really important for us to build technology that will help us meet patients where they are," said Tatiana Blue, manager, IT innovation, NewYork-Presbyterian. "Telemedicine gives us the ability to do that. [Patients will be] able to do these virtual follow-up visits from home. They won't have to worry about typical barriers to care, such as transportation, needing childcare or taking days off of work."
Addressing Maternal Disparities
The United States has the worst maternal death rate among high-income countries studied. A 2019 analysis found that approximately 700 women a year die from pregnancy-related complications, either when pregnant, during childbirth or in the year after pregnancy. About 60% of these deaths are considered preventable.
Racial and other disparities are persistent factors among maternal deaths. According to a 2019 study, African American, American Indian and Alaska Native women are two to three times more likely to die from pregnancy-related causes than white women. Other social determinants of health, including low socioeconomic status and inadequate education, also contribute to a mother's and infant's health.
"We know that unaddressed social determinants of health in the first three years of life can have substantial downstream consequences and contribute to multigenerational health risks for both the mother and child," said Liora Hoffman, manager, Psychiatry and Adolescent Clinical Services, NewYork-Presbyterian Morgan Stanley Children’s Hospital.
To better serve its diverse patient population, NewYork-Presbyterian has made maternal health and early childhood development a strategic priority. Using publicly available data and working with obstetrics, mental health and pediatrics health care providers, this program will create a risk stratification approach and target this intervention to subgroups within its patient population who need extra maternal and infant support. Data identified from an in-depth report by the Citizens Committee for Children revealed that more than 13,000 children live in the Washington Heights neighborhood that NewYork-Presbyterian serves, and roughly 35% of those children live in households that earn less than the federal poverty level.
"It's important to understand the needs of our community and our households with children so we can know how to design interventions for this population," said Davina Prabhu, vice president of the Ambulatory Care Network in the Division of Community and Population Health at NewYork-Presbyterian.
Since 2018, NewYork-Presbyterian has been implementing universal screenings of social determinants of health in its primary care practices, offering closed-loop navigation and referral linkage to those patients deemed to be high risk. This means it has been able to refer patients to social services and closely follow up — or close the loop — to ensure needs are resolved. This program is part of the Accountable Health Communities Model funded by Centers for Medicare & Medicaid Services. Coupling this program with telehealth will help provide comprehensive care to families with the highest risk.
Enhancing In-person Visits
The telehealth pilot builds on an established, evidence based national model called HealthySteps, which provides one-on-one support for families with young children. This program adds a child-development specialist to the primary care team to coach mothers on positive parenting strategies, promote healthy attachment and optimize child health and development.
Research from the Modern Medicaid Alliance shows that HealthySteps significantly improves outcomes for children and their parents, while saving Medicaid up to $1.2 million a year by encouraging appropriate use of care and reducing unnecessary emergency department visits.
Currently, HealthySteps is offered at one out of the four NewYork-Presbyterian community-based, hospital-affiliated primary care practices. "It's been an extremely effective intervention," said Hoffman. "However, the program is only offered via face-to-face clinic visits. We have families lost to follow-up because they have difficulty making it into the office." This is of particular importance when addressing maternal mortality, as a third of the deaths occur up to one year after delivery.
The telehealth pilot is intended to reach those families who may be at risk of missing appointments. A child development specialist will conduct virtual video visits for expectant mothers, from the third trimester of pregnancy through the first year of their child's life.
"The virtual visits will allow for a unique view into the home environment," Hoffman said. During prenatal virtual visits, the child development specialist can help advise the family on how to best prepare their home for the birth of a child. For instance, the specialist might ask to see where the child will sleep. As the baby grows, the specialist will look to see if the family is continuing to keep their home safe for a toddler.
"We're also going to focus on healthy attachment," Hoffman said. "The specialist will be able to observe the mother and baby in their natural home environments to be able to support positive parenting techniques."
Blue stresses that NewYork-Presbyterian is not looking to replace in-person visits with telehealth visits. It's more about enhancing in-person offerings. "We're looking to improve volume and access — and what that does is improve outcomes," Blue said.
For example, during a telehealth postpartum visit with a new mother, the clinician might see that the patient is having trouble controlling her diabetes and recommend an in-person appointment with a primary care doctor or endocrinologist. "Telehealth really allows us to reach patients in between scheduled in-person follow-up visits," Blue added.
Leveraging Telehealth Platform
NewYork-Presbyterian is ahead of the curve when it comes to telehealth. The health system's NYP OnDemand service already offers patients a number of options for connecting to clinicians, including video-based visits with providers, virtual urgent care visits and second opinions via a patient portal.
This experience is proving helpful in rolling out the virtual visits with expectant and new mothers. However, the maternal health team needs to consider how to customize the digital platform to best engage their patient population targeted by this program.
"There is not a one-size-fits-all telehealth program for all of NewYork-Presbyterian," Blue said. "We may have to tailor some things to be culturally sensitive, understanding the language that patients speak and meeting them at their level of health literacy."
Helping Clinicians Help Patients
While innovative, telehealth technology is only one way to connect patients with their providers. "Our leadership guides us to think about technology as a very small piece of the puzzle, only 5%," Blue said. "Eighty percent [of the puzzle] is people, and the other 15% is process. So we lean heavily on our clinicians [to make this work]. They know their patients."
Prabhu agrees, and points out that it was people, not technology, who came up with NewYork-Presbyterian's award-winning telehealth idea. "Having committed clinicians and teams that come together to come up with innovative ideas for our patients is of utmost importance, and the key to success in doing any of this," she said.
Brief Case Studies
Where Do Innovative Ideas Come From?
Parkview Health was the 2018 winner of the AHA Innovation Challenge, which is sponsored by First American Healthcare Finance. With the $100,000 award, Parkview Health is building a digital tool that will allow patients with addictions stay in contact with peer recovery coaches, who guide and mentor people through recovery.
How can other hospitals come up with innovative ideas? "Innovative ideas come from a variety of places," said Connie Kerrigan, director of outreach. "They come from looking at a unique problem and trying to decide what kinds of things you can do to address an issue." Watch the video.
"We continue to sponsor the Innovation Challenge because we're equally as passionate as providers in making a difference. Innovation can change the way patients receive care and the overall health of communities." –Lori Dennis, senior vice president, First American Healthcare Finance
Taking the Chaos Out of Policy and Procedure Management
Island Hospital used to have a disorganized process for handling policy and procedure violations. Department managers and safety officers would exchange 40 to 60 emails discussing how to address each violation. "We were burying critical information — and sometimes staff wouldn't take action because there were no clear next steps," said Sandra Sheikh, quality improvement coordinator & safety officer.
After implementing a policy and procedure management software solution, Island Hospital now has clear documentation showing what policy or procedure was violated, how that violation was remedied, and who signed off on the action. Learn more in this case study from NAVEX Global.