Season 2, Episode 9: Maternal Health Innovation Program

Listen to this week’s episode to get an understanding of the Maternal health Innovations grant, which coincidentally (or not), funds this podcast! Join five family medicine providers as they discuss the projects they are working on that contribute to the world of maternal health in all of North Carolina. 

“I Gave Birth” Bracelets: https://www.mombaby.org/2023/erase-maternal-mortality/ 

IMPLICIT: https://www.fmec.net/implicit 

Maternal Health Innovation Grant Resources: https://mahec.net/regional-initiatives/maternal-health-innovations-grant 

Podcast Survey: https://redcap.mahec.net/redcap/surveys/?s=XTM8T3RPNK 

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Transcript

Intro [00:00]: Hi everyone, and welcome to just us before Birth and beyond. We're so glad to have you with us today. My name is Caitlin, and I am one of the hosts of our podcast. I am a nurse and have been a nurse in Western North Carolina for the last 10 years, and I am here today as a prenatal nurse champion for region one. And this may not mean anything to you as you're listening to this podcast, but that is actually what we will be talking about today. So, on this episode of just us, and we have Dr. Dr. Amy Santin who is a family medicine champion for the West in the state of North Carolina, and she's talking with all of the other family medicine champions for the state of North Carolina about the Maternal health innovations program. So, in this episode, you're going to hear about what the Maternal Health Innovation program is, what exactly it means to be a quote, unquote champion, and they're going to discuss some of the work that they are doing specifically around the fourth trimester postpartum period for patients and why it's so important for family medicine providers to be a part of these postpartum and fourth trimester conversations. So, we hope that you enjoy this episode and without further ado, let's get into it.

Dr. Amy Santin[01:25]: Hello, welcome to the Just Us Before Birth and Beyond podcast.   My name is Dr. Amy Santin. I am a family physician on faculty with the Mehag Family Medicine Residency in Asheville. I am one of six family medicine champions in the state working on the maternal health innovation grant. This is a HRSA funded grant awarded to the state of North Carolina with the aim of reducing maternal mortality in our state. So, today I have with me the other five family medicine champions. Across the state we have Dr. Narjes Ferjani family physician on faculty. At UNC, we have Dr. Jan Basti, who is the residency director for the Novant Newham of our Family Medicine residency, Dr. Mona Chao with the Rural Health Group in Roanoke Rapids, Dr. Keyona Oni on faculty with Wake Forest, atrium Health in Charlotte, and Dr. Carmen Strickland who is on faculty at Wake Forest.

So, today we're going to be talking about the unique role that primary care providers play in reducing maternal mortality, and before I turn to these family medicine experts I have with me today, I just want to give a little bit of background on the grant that we're working on. So, for purposes of the maternal health innovation grant, the state is divided into six prenatal regions in each region. We have an OB champion, a family medicine champion, a nurse champion, and new to our group are pediatric champions. We're all working together in our regions on initiatives aimed at reducing maternal mortality. The idea behind this model is that each region in the state is really going to vary in terms of its patient populations, its health needs, its health delivery systems and those sorts of things, and that a one size fits all approach really probably isn't going to work well. So, this really gives us some leeway and creativity to craft unique strategies to improve maternal care within our own specific region. And this endeavor is really important. North Carolina has a lot of room for improvement as we currently rank number 30 in the country with regards to maternal mortality.

Traditionally, I think a lot of efforts aimed at reducing maternal mortality. Were focused on intrapartum care, like what is happening in the hospital on the L and D wards, obstetrical emergencies or things that happen one to two days after delivery while a patient is still hospitalized. But we know that the majority of maternal deaths occur in the postpartum period. 45% of maternal deaths occur between day one and 42 days after delivery, and then in additional 17% occur from 42 days up to a year after delivery. So, this is a time when many moms are no longer being followed by their obstetrician and a time when they might instead be showing up in our offices as pediatricians and primary care providers. So, family medicine physicians were invited to the table to join this discussion because of our expertise in treating a wide variety of conditions that contribute to postpartum morbidity and mortality, we're adept at treating patients across the reproductive lifespan.

So, we have multiple opportunities to screen and intervene to reduce risks. So this includes providing intercom care, contraceptive counseling, screening moms at well child visits for things that can negatively impact her health, and this is an area where our pediatric champions are really adding so much value to our work since they have so much access to new moms who might be prioritizing their children's well-child visits and maybe at the expense of attending their own primary care or postpartum visits, we can optimize preconception health to improve future pregnancy outcomes, and really importantly, we're highly skilled at chronic disease management, and this is so important because chronic diseases like hypertension, diabetes, tobacco and substance use disorders, obesity just to name a few, these are things that really impact on increased pregnancy risks, and then conversely, adverse pregnancy outcomes, conditions like preeclampsia, gestational diabetes, gestational hypertension, abruption, these are all risk factors for premature cardiovascular disease and early death.

So, pregnancy in the postpartum period are critical access points to reduce these future risks. So, if you want to decrease maternal morbidity and mortality, having family medicine physicians at the table is critical along with pediatricians and the multiple other providers that we work with in this grant, including of course our OB colleagues, nurses, midwives, doulas public health experts, it takes that whole team. So, with that in mind, I'm going to turn to our other champions now to highlight some of the innovative things that family medicine physicians are doing in this realm. So, Dr. Oni and Dr. Chow, I know that you both have done some work on this important concept of transitions of care, which is a big aim of our grant and one of the things that we're working on, it's been well documented that women are often lost to care after a delivery as they focus on their newborns. How can family physicians be involved with ensuring that medical conditions that develop in pregnancy have ongoing care?

Dr. Keyona Oni [07:17]: I think it's a complicated question because there are multiple layers that create both self-inflicted barriers to accessing the healthcare system, but also sys systematically, and politically like barriers for patients to access the healthcare system in general, but even more in the postpartum period. I think on the provider standpoint, from a family medicine position, we're really primed to care and re-accept patients after their delivery and immediate postpartum care with their OBGYNs because we have been caring for them and their family we're trained in chronic disease management and prevention, which I think is a unique perspective that other subspecialists cannot provide, and so that being said, our training prepares us and equips us to care for our patients in that framework. One way, and I've seen a few models of this where family medicines can remain engaged in those conversations, whether you're doing prenatal care or doing deliveries, is to partner with some of your women's health clinics and OBGYN's clinics and developing an algorithm to self-select those who are in those highest risk groups.

Like you mentioned, patients who carry a diagnosis of obesity in pregnancy or have been named to have a hypertensive disorder in pregnancy, specifically because of the associated risk for early onset of cardiovascular disease and cardiac death, which is a serious condition to consider in that first year or fourth trimester of pregnancy. So, partnering with your OBGYNs to identify who those patients might be and thinking in their prenatal period for them to identify a primary care clinic or provider to see and as a transitions of care visit, that's one of the things that we have been looking at specifically in Charlotte as we are seeing much more many more patients come into pregnancy with chronic disease. How do we identify those in pregnancy and get them an immediate transition of care clinic visit with a primary care office and really aiming for, like you said, that four to six week period after delivery when we know their ongoing risk for developing morbidity.

Dr. Amy Santin[10:02]: Great. Can any of you maybe speak a little bit to what some of the barriers are for the providing that smooth transition from intrapartum to primary care setting?

Dr. Chow [10:17]: I would like to just add briefly to what Dr. Oni said. Definitely as family doctors by training, we are super well positioned to take on the more chronic metabolic and cardiovascular diseases that pregnancy complications often portend for the rest of that person's life. Speaking as an early career attending in a federally qualified health center in a rural area, certainly one thing that has been really interesting in terms of seeing how care is delivered in rural areas is that often like adult medicine and pediatrics and OBGYN is very siloed compared to what my family medicine experience have been in residency in medical school at UNC, and one thing that Dr. Dorsey, the pediatric champion also at Rural Health Group and I have been working on just within our own organization here in region six in Halifax County, is to try to break down some of those silos in those barriers to communication and actually implement that concept of a fourth trimester as well as an ICC questionnaire at our pediatrics and family PA offices, as well as start having conversations with our local OBGYNs about creating a postpartum care plan that can help patients navigate that transition from the inpatient to outpatient and OB to primary care realms.

Dr. Keyona Oni [11:52]: And to add to your questions, you asked about what barriers might exist, one of the barriers that exist are centered on policy in healthcare coverage and historically in North Carolina getting for some patients, getting access to care or getting insured care after your delivery was quite challenging. So, more needing more of that primary care transition and follow up after your six eight week period was challenging, and finding practices that would accept uninsured, underinsured, or even undocumented patients creates poses significant barriers, especially for North Carolina when we have a very large percentage of populations who are undocumented and underinsured. So, that poses a greater threat now that we have better coverage in the postpartum fourth trimester period that improves access but doesn't resolve the issue. The expansion of Medicaid hopefully would be helpful.

Dr. Amy Santin[13:03]: Yeah, so that was has been really great news for the work that we're doing, especially as we realize that barriers exist every step of the way on providing for that smooth transition. So, every bit, well, great. Dr. Bestie family physicians often see young children in their practice as well as their mothers. How can they effectively address issues that have an impact on both the children and the moms? And then as a addition to that, how can family physicians work with pediatricians to improve the health of the family?

Dr. Bestie [13:40]: Yes. I'm going to build on some of the things we talked about earlier. So, the former president of a cog, Dr. Eva Charles, said that a woman's pregnancy is a window into her lifetime health, and we as family physicians know that in addition, a woman's health is a window into the health of the family. The woman is often the person who's the caretaker, the one who's bringing people into healthcare, and as caretakers moms often neglect their own health to care for others. We talked already during the postpartum interception period, 35 to 40, maybe up to 50% of women missed their postpartum visit. However, as we know that women almost always accompany their child to their well child visits. So, that gives us 10 visits in the first two years of life, maybe a little bit more, including visits for fevers, ear infections, rashes, spitting up all the things that we see kids for acutely in addition to their routine well childcare.

So, this gives you opportunities to also address the health of the mom. So, as family physicians, we're very comfortable with the idea of caring from multiple members of a family. We see them as part of a family union. All of us have had the experience of seeing a husband who then mentioned something about his wife or a woman who mentioned something about her mom or her kid. We're very comfortable with that interconnected unit idea. In the early 2000, a group of Northeastern family medicine residency practices formed a network at that time to collectively work on reducing the incidence of premature and low birth weight babies. It was called implicit interventions to minimize preterm and low birth weight infants using continuous quality improvement techniques. That's why they go with the name implicit. It's a family medicine learning collaborative focused on improving birth outcomes and promoting the health of women, birthing people, infants and families through innovative models of care, quality improvement and professional development.

However, it became clear early on that pregnancy outcomes really depend heavily on the health and the lifestyle of a woman. Before her first prenatal visit in 2006, the CDC recommended using that interconception period, the period between one pregnancy and the next to improve maternal health prior to subsequent pregnancy. However, there was no widely accepted model on how to do this. They just said it should be done. So, of course, being family physicians in 2010, this network decided to shift their focus to interconception care. So, this interception care model screens women for smoking, depression, family planning or pregnancy ness and multivitamin with folic acid intake during baby child visits between birth and 24 months of age. So, this network has grown beyond the northeastern United States and includes practices in North Carolina, including our residency practices in Asheville and Chapel Hill, Wilmington, as well as some pediatric practices, as well as some other primary care practices.

And this network has actually published some studies on this interception care. So, studying the animals of family medicine in 2016 showed that 95% of moms were willing to accept health advice from their child's physician regardless of whether that was their primary care practice or not. And in 2021, Dr. Daniel Fran from Asheville published in Maternal Child Health Journal that the implicit model resulted in increased reported healthcare provider discussions of four key areas of InterCon health by mothers attending their well-child visits. So, this model holds a promise as a primary care strategy to systematically address maternal risks associated with poor pregnancy outcomes. So, what we've shown so far is women are willing to accept this advice and it increases the conversations that we have about these things. So, one of the things that we early on decided is we can't do this alone. We needed our pediatric colleagues to help with this.

And family physicians with pediatric colleagues are in an ideal place to address this gap in women's healthcare. So, we ask some questions during child visits, issues pertaining to mom's health, are you taking a multivitamin, met folic acid? We do a depression screen, either the PHQ two or nine or the Edinburgh postpartum depression screen. We ask if they smoke or if they were a smoker prior to pregnancy, and does the form of contraception that they're using match their pregnancy intended this? And so that's questions about do you want to be pregnant? And if so, are the things you're doing right now match your plans over the next year? So, collaboration with these pediatricians can result in warm handoffs from pediatric practices to family medicine practices. Family practices can set up times to address the mother's needs or work to create diet visits where mothers and infants are seen together.

In our practice, we do this at the one month visit, we often combine another postpartum visit with the one month child visit, and we just make it an extra-long visit and we're able to address both those things together. Physicians, the barrier really is physicians are concerned about how much time this is going to take. Child visits are already jam-packed with screenings and advice and anticipatory guidance. And so this model really emphasizes not dealing with the problem right then and there. It really emphasizes having a plan. So, if a mom screens positive, you have a plan to do something with them. So, for example, if a mom states she's not taking multivitamin, all you have to do is say, I recommend she take multivitamin with folic acid. If they screen positive on a depression screen, you have a plan in place to make sure that they get into treatment either with their primary care doctor or with a pre-assigned pathway that you've already decided as to where people go.

And as was mentioned earlier, the recent expansion of postpartum Medicaid to 12 months really has made a big difference because before they would screen positive, and they didn't have insurance and we had nowhere to send them. So now because they have Medicaid, we usually do have pathways to send them to deal with positive depression screen or smoking or needing contraception that doesn't match their plans for pregnancy intended disc, and for those who have collaborations between pediatrics and family medicine, the pediatricians can basically say, I'm handing you right off to these family physicians. If you don't have a primary care provider family practice can use usually then just schedule the mom and other visit to address those issues that come up during those screenings.

Dr. Amy Santin[19:40]: Yeah, thank you. So, you mentioned how well situated we are as family physicians to do this work because usually the infant is our patient, and the mom might be our patient as well. Can you speak a little bit to some of the barriers that you imagine occur in the pediatric setting, with their screening moms who aren't their patient?

Dr. Bestie [20:06]: Of those four things we screen for, only one is paid for the postpartum depression screening, and that's only paid for four times in the first six months of life. Adding more work for what you're not getting paid for is a barrier, and also, particularly in certain areas, even if you identify that this mom needs intervention, there may not be anybody willing to do it. I know in region five, as we've talked with particularly OBGYNs who've talked about trying to refer women back to primary care for healthcare issues as there's just not enough people to take care of them, and so in certain areas, the pediatrician may be one of two pediatricians who take care of kids in this community, and there's just nobody that they can send these moms to, and so that from my conversations with people around my region has been the biggest issues. There's just not necessarily enough people to refer these folks to for care.

Dr. Amy Santin[20:58]: Do you imagine that those people exist in your region and we just haven't tapped into that resource yet or is it a matter of just simply it's the primary care shortage?

Dr. Bestie [21:10]: My impression, and I think probably was born out by statistics in the state, it's a shortage, and also to be perfectly frank, for some of these moms who have Medicaid may be a shortage of comprehensive physicians who will take Medicaid, and I think in some areas there may only be a handful of physicians who will take Medicaid and they are just overwhelmed and there's not enough of them to do that.

Dr. Amy Santin[21:41]: Okay, great. Thank you Jan. Dr. Ferjani, we know that hypertensive disorders of pregnancy are common in North Carolina and contribute to maternal morbidity and mortality. What do family physicians need to know even if they themselves don't provide maternity care?

Dr. Narjes Ferjani [21:59]: Thank you so much for this question. So, you are exactly right. Hypertensive disorders of pregnancy impact over 10% of pregnancies, both nationwide and here in North Carolina. These hypertensive disorders include patients with preexisting or chronic hypertension, gestational hypertension, preeclampsia with or without severe features, and postpartum hypertension. Hypertensive disorders of pregnancies are a leading cause of pregnancy related morbidity and mortality, and these deaths related to hypertension are mostly preventable. As you had mentioned earlier about head pregnancy related morbidity, and mortality more broadly, as physicians who see reproductive age women and people with a capacity for pregnancy in a wide variety of clinical settings, family physicians have an important role to play in identifying at-risk patients and prevent the devastating outcomes. But currently, most of the guidelines focus on safety and quality of care for severe hypertension have been focused in the hospital setting. But as we know, as many physicians, pregnant and postpartum patients often seek care in a lot of different settings, primarily in outpatient clinics as well as urgent care centers and emergency departments.

And so here in our region, we are working to develop a model and a bundle of best practices for addressing severe prenatal hypertension in the outpatient community setting where most people are going when they have either high blood pressures or symptoms that may be a sign of a hypertensive disorder. So, this is particularly important for us to be aware of as family physicians, especially for family physicians who may not provide prenatal care or any kind of prenatal services because the parameters for hypertensive emergency are different for pregnant postpartum patients than they are in the general adult population. So, there's a possibility that those emergencies could be missed or overlooked. It's essential that family medicine physicians and their clinical staff can recognize the severe ranged blood pressure and are prepared to treat this blood pressure appropriately as the emergency that it is. Recognizing these elevated blood pressure is treating with a safe and fast acting medication and then escalating and transferring to a higher level of care can make a tremendous impact.

These measures can be lifesaving and can prevent major morbidities including stroke. So, in our work here in the central part of North Carolina, we've learned that education for clinicians and clinical staff as well as education for patients and families is essential. So, it's critical that patients and their loved ones recognize the warning signs of severe hypertension or preeclampsia, and in our role in primary care, we provide patient and family education in so many different aspects of our work. So, there are many opportunities to be incorporating education on those maternal early warning signs into that whenever we have contact with patients who are either pregnant or postpartum, it is also essential that the clinical team in any setting or the patients seek care, recognize the concerning symptoms and the severe range blood pressures. So, in pregnancy and the postpartum period, any systolic blood pressure of 160 or greater or a diastolic blood pressure of 110 or greater is an emergency.

And in our region, we've adapted the severe hypertension in pregnancy safety bundle that from the Alliance for Innovation and Maternal Health for outpatient and have developed a clinical outcome that has a clear kind of stepwise approach, almost like a kind of checklist type algorithm for pregnant or postpartum patients who are found to have that severe rearranged blood pressure. So, these resources are now available for all providers in our region on our website with accompanying education resources for patients and clinicians in our clinic. And I work actually at a rural fellow qualified health center in Prospect Hill, North Carolina. We've adapted this algorithm and have done simulations based on it in our clinic, and we really found it to be practicing meeting and just for me, but for kind of our entire clinical staff, we're working on sharing these resources more widely in our region and really hope to do that across the state as well.

Dr. Amy Santin[26:03]: That's so great. Thank you, I love how that's such a nice example of what I was talking about of how we're working within our regions on things that make sense for our particular region. So, that's a nice example of what you're doing, and I know some of the other regions are doing their own things in this regard, and my other comment is, wow, what a daunting task when you think about all the different kinds of healthcare providers that might see this patient, including urgent care, emergency medicine, family medicine, it could be internal medicine, that's a lot of education to other providers, it's a daunting task.

Dr. Narjes Ferjani [26:49]: Yeah, absolutely. Interestingly, the Joint Commission has made it a requirement for emergency departments to have a system in place for identifying pregnant or recently pregnant patients and in place around severe hypertension. So, I think as some of the kind of regulatory bodies and other potentially like payers who are involved in kind of setting quality and safety standards for hospitals really adopt more of the kind of perinatal health safety standards as well. I think there'll be more of an emphasis on it. I think it's so hard to focus on all of the different metrics out there, and I think as this is really elevated as something that's really important by things like joint commission or Center for Medicaid and Medicare services, sometimes it can be a hard for different settings to make that a priority, but we've definitely noticed that an our emergency department wants the joint commission put an emphasis on this. Then there was more openness to incorporating that staff education and the having some of the algorithms incorporated into their workflows as well.

Dr. Chow [28:11]: Another cool piece of it has been actually patient education too, of postpartum risks and like their own blood pressure parameters to be aware of, particularly if their pregnancy was complicated by PIH, and something that the ECU folks in region six have been working on too is providing birthing parents with, I gave birth bracelets, and often we'll see new parents in our clinic still wearing their bracelets from their L and D experience. That is another way in which those other healthcare facilities like EDS and urgent cares might also be prompted to be more aware of that recently postpartum state.

Dr. Amy Santin[28:54]: Yeah, that's great. Thank you for adding that, Mona, I think it's really important the point that you made [Inaudible 29:01] about educating patients and I think that oftentimes patients don't understand the complications that they had during their pregnancy, that they have this risk factor that sets them up for adverse outcomes in the future. So, part of the work that we're doing is trying to educate patients and then also have a system where that information can be relayed, for instance, from the obstetrician to the primary care provider or to the pediatrician to, so everyone can keep an eye on it, but I think a lot of times it that crucial information falls through the cracks. So, that is also a big part of the work that we're doing. Dr. Strickland, tell me about some innovative models of caring for women during pregnancy and during children's childcare.

Dr. Strickland [29:50]: Sure. So, happy to join everybody today, and I have a particular interest in group models of care and there are group models of care that have been in practice now for a number of years both for providing pregnancy care as well as more recently for providing childcare, and I am a proponent of these models for several benefits that I have experienced personally, and am aware of as I work with practices that are implementing these. So, first just generally explain the concept. We've had standard elements of prenatal care in our country for decades, and in group models of care, the same elements are being provided, so the same care by the same providers. What's different is that the components come together in a different way, and we essentially ask patients to share the time that they spend with their provider with other patients.

So, in pregnancy care, this would be women at the same gestational age that would share the equivalent of their prenatal visit with a group of other women, usually up to a number of eight to 10 women per visit, and in, well childcare it would be babies at the same age receiving care along the standard schedule of preventive pediatric care, and a lot of several things happen once you make that one fundamental change. Once a group of women have decided and volunteered to share their time with a provider together, you now have an increased amount of time to spend with those women in a more in-depth conversation about the pieces of their prenatal care. You also have providers hopefully that have had some training in how to utilize that time in a sort of enhanced way, so that really maximize on what happens in there, and you also allow those patients along with the provider to gel as a group, to get to know each other and provide a level of support with and for each other that's not really able to be present in a traditional one-on-one visit.

But ultimately, once you see how that care happens and recognize those, those enhanced features of a group visit, what ends up happening is I think higher levels of conversation, and also ability to really problem solve because with the extra time and the elevation of all the voices that are there, so patients become comfortable really sharing the places they get stuck and then there's this time to reflect back and help them overcome challenges that I think allow us to perhaps get through and ultimately achieve improved outcomes. There's also this improved trust in the healthcare system. I think that comes from this model because women really are a little, it may be new or less familiar to have time to really get to know their providers and start to really see us as being there to help them through everything, and additionally, I'd say the providers themselves learn more because they're in a listening mode.

They actually often can understand things about the community they're serving that they might miss in rapid one-on-one visits that are a little less bi-directional, and then because of that, I'd also add, I generally sense providers expressing an improved satisfaction with the care. There's this rewarding part to delivering care that really feels where you've delivered great greater impact, I guess, and connected with people on a different level. So, ultimately, I would just encourage, I find the group models, I think have a role in improving outcomes, again, I guess for providers and for patients, and they are growing in the healthcare system, but it is new and different, and so that that takes time to get everybody comfortable with revising how delivering care.

Dr. Amy Santin[34:05]: Yeah, what a great model. It just sounds like it improves satisfaction all around and is very patient centered. So, I guess getting away from the traditional model where we as healthcare providers advise and we have no idea whether or not the patient is in a space to receive what we think is the most important thing on the agenda. So, I love that. Is there data to support outcomes, improved outcomes with this model?

Dr. Strickland [34:35]: Yeah, great question, and the answer is yes, there is. There's just several things that kind of come to mind. One of the outcomes that's been most intriguing with centering pregnancy is specific model for pregnancy care in groups is reduced rates of preterm birth, and of course it's difficult to understand exactly why, but, but there's some interest in the idea that both the attention to following all of the best practices that we advise, perhaps there's some improved ability to really meet those best practices, nutrition and prenatal vitamins and just access to care, and those pieces. But there's also some growing interest in the idea that stress is reduced among women who are pregnant and that there may be a true impact then or effect on preterm birth, and so a lot of interest now in looking into even markers of stress, bioavailable markers, that sort of thing.

In addition, there tend to be fewer visits to the emergency room, fewer calls back at presumably because there's been a ability to really explain and have patients understanding things that maybe having fewer questions later there's an increased sort of confidence. Labor nurses have commented that patients coming through group models of care are a little bit more familiar with what's going to happen on labor and delivery and they really ask advocate for themselves and tend to have a different experience and are able to communicate better with their healthcare system, and we think that adherence to visits is improved a bit and are hopeful that we'll see the same with the well child visits that will have improved adherence and perhaps then improved delivery of immunizations and all of the equivalent best practice and advising that we do for child our well child care. So, those would be all things that are intriguing about to leverage this model.

Dr. Amy Santin[36:41]: Yeah. That's wonderful. Is our group visits covered by insurance?

Dr. Strickland [36:47]: So, that's a really important point to emphasize. So, this is, again, as I said in the beginning, same elements of care are provided, the same monitoring and assessment is happening, and insurance sees group care as delivering exactly the same service essentially as traditional care, both in pregnancy and then similarly in well child visits. So, yes, the answer is that there is nothing about the visits is in addition to prenatal care or childcare, but this actually is meant to be a replacement for traditional one-on-one care and it is reimbursed in the current standard models of payment.

Dr. Amy Santin[37:31]: If providers or any of our listeners are interested in learning more about this model, where could they go?

Dr. Strickland [37:38]: So, specifically for the centering model, there is a website and an organization that's able to provide some support and assistance, and also at the level of the state there is support for centering. So, through the Department of Public Health, there is sometimes funding available. So, just checking in to see if there's any, any sources of funding to assist with training, and then the last thing is in the state of North Carolina, there's a traditional group of centering sites and stakeholders that are interested in group models of care and there's, they tend to meet twice a year, and so there it's through the depart Department of Public Health, you could access the folks that are running the centering consortium and get connected to other folks that are doing a centering kind of model or good care model, and then I think that's a great place to learn more about it and get started.

Dr. Amy Santin[38:33]: Great. Thank you. My pleasure. All right, great. Thank you so much everyone for sharing your thoughts and some of the work that you've been focused on. Before we end, I just also wanted to point out that I just wanted to have a word about health equity and that all of the work that we're doing as part of this grant is conducted through a health equity lens, and we know that there's wide disparity in women's disease mortality rates by race and ethnicity in North Carolina as well as nationally. And this certainly holds true for pregnancy related deaths. African American women across the income spectrum die from preventable pregnancy related complications at three to four times the rate of non-Hispanic white women. And that's just one fact. Of course we could have a whole podcast on that, but we're doing lots of work in that regard because that is a really important factor if we are wanting to improve our maternal mortality statistics. So, it's really embedded in all the work that we do and one of our fundamental guiding principles. So, with that, I don't know if anyone has any further comments or questions. Okay. Thank you all so much.

Outro [40:03]: What another great episode. I really enjoyed the action items that came from this episode. So, there was a lot of discussion around things that providers and birth workers could do to incorporate this awareness and attention to the postpartum period, like the postpartum care plan I gave birth bracelet project, touching on how pediatricians can be helpful in the postpartum period. Just a lot of great information, all of which will be linked in the show notes below. So, if you heard anything on this episode that you want to do a little bit of a deep dive in, please make sure to check out our show notes. We would also really appreciate a five star review; some comments we would love for you to share some of our episodes with others in your network. We also, in our show notes have a survey linked. We would really appreciate your feedback if you wanted to take the five minutes that it might take to fill out the survey. You can not only give us feedback, but there's also a place to suggest future episode topics. So, if y'all wouldn't mind, we would really again appreciate the feedback, and until next time, thank you so much.