U.S. Health and Human Services Department Secretary’s Postpartum Maternal Health Collaborative Expert Evidence Convening

Milbank Memorial Fund Proceedings

Executive Summary

With direction from the U.S. Department of Health and Human Services, the Milbank Memorial Fund convened four panels designed to synthesize evidence and opportunities for postpartum mortality reduction to inform the Postpartum Maternal Health Collaborative. These “expert to expert” discussions included state members of the collaborative and additional subject matter experts such as academics, payers, health care providers, and representatives from other states. Panels were convened on the following topics: mental health and substance use disorder (SUD), community and social drivers of health, clinical care, and state-level policy opportunities with a particular lens on addressing persistent and striking disparities in outcomes.

Below are the key themes from the four sessions, and a synopsis of each session, including presentations and group discussion. Sessions were moderated by Drs. Morgan McDonald and Lisa Dulsky Watkins of the Milbank Memorial Fund. The format consisted of brief recommendations from panelists followed by discussion with state teams. (See Appendix A for list of presenters, and Appendix B for list of state participants.)

Key Themes

Panelists and participants identified the following areas for state policy action:

1. Enable Better Transitions in Care with Technology, Patient-Specific Care Planning, and Outcome-Focused Payment Systems: Maternal mortality review teams have repeatedly shown care transitions are high risk for patients with complex social needs or diagnoses such as hypertension or substance use disorder (SUD). Integration of wraparound telehealth, virtual patient monitoring, immediate patient communication, and intensive care coordination is an expanding area of innovation that increases patient engagement and care transition quality for patients who are connected to a care team. Payers should develop and test reimbursement models that incentivize and enable patient-need driven transitions without duplicating care coordination services.
2. Provide Resources First; Then Screen and Refer: Providing resources to all patients before social risk, SUD, and behavioral health screening increases trust between the patient and provider/health system by demonstrating institutional readiness, normalizing receipt of such services, and alleviating fear of discrimination. Many patients may be reticent to disclose social or behavioral health needs or high-risk behaviors if they do not know that needs will be met, particularly if there is a perceived or real risk of child protective services involvement if they use substances during pregnancy. Thoughtfully involving the other care team members (i.e., community health workers) can identify opportunities to build trust and accurate assessment of needs and resources.
3. Ensure Cross-Sector Collaboration in Policy and Program Implementation: State agencies and task forces should coordinate efforts between the public health departments, hospitals, Medicaid, Children’s Health Insurance Program (CHIP), managed care organizations (MCOs), doulas, community health workers, social service providers, and behavioral providers to address gaps in care (particularly behavioral health and substance abuse) and measure progress in maternal health outcomes. Often, social support services already exist and are not at capacity in communities but the connections to them are underutilized. Likewise, policies such as plans of safe care or reporting of substance abuse need to be coordinated among agencies and providers. State experience shows that a coordinating entity needs to understand the landscape of services and priorities and ensure that entities working on the same priorities are coordinating approaches but that there is no one “right” way to form those connections (i.e., approaches in Indiana, Tennessee, and North Carolina differed drastically
   but worked).
4. Incorporate Community and Patient Engagement: States need to be students of implementation science as they create policies and programs to enable patient care. Opportunities such as postpartum insurance coverage extension, inclusion of doulas and other covered services, and enhanced home visiting programs are only effective if patient, provider, and community voices are relied on during the design, implementation, and evaluation of programs and services. Just as initiatives such as the “Hear Her” campaign need to be lifted up to ensure patient voices are heard in clinical care, the patient voice must be represented as changes and improvements are made. States can leverage the variety of existing mechanisms to engage with patients/beneficiaries/consumers.
5. Support and Expand Quality Improvement Initiatives: Existing quality improvement initiatives demonstrate positive outcomes. States should support ongoing integration of patient safety bundles and participation in perinatal quality collaboratives with ongoing funding, particularly in low-resource and small-volume/rural clinical settings.
6. Patient-Centered Care: States should seek precision in connecting patients with interventions. Addressing the needs of a postpartum mothers in need of treatment for SUD may differ substantially from someone who needs to address cardiac risk, for example.
7. Data Infrastructure Investment: Finally, states should prioritize data collection so that existing initiatives and value-based payment initiatives can be evaluated and improved. Likewise, data disaggregation efforts should be incentivized across all sources to assure that no populations are excluded from improvements in postpartum morbidity and mortality