Improving Access to Risk Appropriate Care and Maternal Health Outcomes through Provider Engagement

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: urgently working to reduce the nation's maternal mortality rate, one of the highest among high-income nations.

LILY LOU:
I think that healthcare resources are concentrated in a way that doesn't match the needs.

EUGENE TOY:
I think it just needs to be done yesterday. Our maternal mortality rate is through the roof and is a major, major problem.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we examine risk appropriate care strategies as a way to reduce America's high maternal mortality rate. In 2020, the CDC says 861 people died of maternal causes. The CDC also estimates that 60% of those lives could have been saved. So how does risk appropriate care figure into the solution? Our guests are here to answer that question.

Dr. Lily Lou is the former chief medical officer for the state of Alaska. Today, she's a professor of clinical pediatrics at the University of Illinois Chicago. Dr. Lou has a long resume of work in medicine and clinical research. She's here later. But first, we hear from Dr. Eugene Toy, an OBGYN in the Houston metro area and a professor of obstetrics and gynecology at the University of Texas Medical School, also in Houston.

TOY:
Risk appropriate care is really the allocation of the people, equipment, the buildings, and just the teamwork for the complexity or the risk of the patients. And in obstetrics and in perinatal, that would be for pregnancy, the delivery of the infant, as well as the treatment of the postpartum patient and also the neonate. And so that that would be the care that needed to be rendered, and implicit in that is that it requires the whole team. And that's one other area I think that we have, in general, in the area of maternal care have been neglectful. We've concentrated on the physician and perhaps some of the technical parts, sometimes on the nursing end of it as well, but not together as an entire team and the communication that is so important in the care of patients.

JOHNSON:
Is that what's been happening? It sounds like it's a little bit of a piecemeal approach.

TOY:
So I think that in terms of the medical care that the traditional model is perhaps a physician- or provider-centric model, and identifying risk factors, diseases, using technology in laboratories to try to identify issues, and then going from there—from the physician's office—to then, if the patient has an acute problem or a delivery, then in the hospital. But a lot of times what happens in the physician's office doesn't get translated to the hospital, or what happens is that there's lack of early identification and prevention.

So risk appropriate care instead really looks at a team model focusing on prevention, and also from the patient side, the community side, and particularly looking at potential issues of access for patients.

JOHNSON:
Can you tell us what a working system of risk appropriate care looks like?

TOY:
Risk appropriate care encompasses the entirety of the patient care—and also involves a patient because a lot of that is education—but all the aspects on the team. So in other words, if a patient were to come into the hospital, it would require not only the nursing care, but also the social services and interaction with the patient from that viewpoint. It would also involve the provider—but not just simply who might be taking care of the anticipated problem, but if the patient has risk factors for other disease processes, then it could be cardiology, ICU, surgery, blood bank, laboratory, etc. And depending on the patient's underlying risk profile, then the particular team that's there may or may not be matched to the complexity. And so that's really the whole basis of risk appropriate care is to match the capabilities to the likely anticipated needs of the patient.

JOHNSON:
It sounds like that doesn't always happen today.

TOY:
Well, it's getting better overall. And one of the biggest changes is the CDC has what's called the LOCATe tool to try to have hospitals and providers to know a little bit more about what goes into the care of the patients. And that's based, by the way, on the American College of OBGYN and Society of Maternal Fetal Medicine obstetrical care consensus document looking at the levels of care and how to match those capabilities to the risk profile of the patient.

So at this point, last time I looked, there were 22 hospitals that used either the CDC guide or in some way use their own system, looking at their own capabilities and trying to match that in some degree with patient risk. So I think we are moving in the right direction. There's increasing awareness of what is required, and I think that there's definitely some good news as far as maternal mortality in some places—for example, California.

JOHNSON:
Can you give us an example of how this sort of thing plays out for the patient?

TOY:
Yeah, I'll give you an example. So for instance, from a physician viewpoint, a lot of times a physician might have been trained in a big hospital, big medical center, so they're accustomed to taking care of very complex patients. And because many times it is the physician that determines whether a patient will be transferred or kept in a particular hospital, they might say in their minds, I have taken care of this type of patient with placenta accreta, let's say—where the placenta is abnormally adherent or stuck to the uterus, and that that can lead to severe bleeding. And so the physician might say I've taken care of this, the patient has a good outcome; and thinking only from the viewpoint of the physician, then caring for that patient.

But when there's complications, and because the whole team—blood bank, nursing, surgery, ICU, respiratory, the whole works—are not really able to care for the patient, then complications can occur. And this is different from a hospital or a system to where upfront, for instance, every hospital has to have a policy to deal with unanticipated or anticipated complications—in this case, let's say this placenta accreta disorder. And so they know upfront, okay, at this level of hospital, even though as a physician I might have dealt with this in the past, we don't have the infrastructure, we don't have the blood bank capability to care for this patient. It is better to transfer the patient early on.

So that's really the key, is each hospital—with guidance from national guidelines and experience—understands what they can take care of safely, which should be referred out, and everyone's on the same page.

JOHNSON:
You've talked a lot about hospitals, and it definitely sounds like they have a role. But what about the providers and the clinicians?

TOY:
I would say that providers have the largest role in making this all work, and the reason why is because the assessment of the risk is clinical. And although our nurses and other people might be able to elicit some of the risk and be able to make that assessment, it's really at the provider level—and usually at the physician level—where identification and then early identification, prevention, and then appropriate referral.

Hospitals are not going to be able to be, by themselves, referring patients. So they depend really on the providers to be able to do that. And speaking particularly on the obstetrical side versus the neonatal side, then generally it is the obstetrical provider who brings their patients into the hospital. And so, they are the ones that have that relationship with the patients, so they would be the ones that the patients trust and also be the ones to help to make this all work out.

And I would say that overall, over the past six years that I've been involved with the maternal levels of care here in Texas, I have seen a dramatic shift in the thought process and receptivity of our physicians. And that is that originally, when the concept of levels of care and risk appropriate care came out, there was a lot of skepticism. And a lot of the doctors just said, "I can take care of this. I've been trained," and in addition, not thinking perhaps in terms of the whole system.

And now, having gone through in Texas re-designation, going through the second round in various hospitals, and doing site visits, we see overall that the doctors have become believers. Because they see doing the multidisciplinary drills, working together and giving input on what needs to be part of the team, advocating on behalf of the patient, and seeing also that the hospital administration is willing to spend the money to be able to increase the quality because they see how important this has been—that there's been a dramatic shift in that change.

And I'm very optimistic about the maternal mortality rate in the U.S. because I believe that there is greater awareness, and the interventions that need to be there and put into place will be implemented.

JOHNSON:
What are some of the steps that can be taken to engage providers if they're still on the sidelines?

TOY:
I think for those who might be reluctant and may not be aware, is just having them learn about some of the adverse events that occur because I think that's where we really learn. For example, as I was learning about how quality improvement and process improvement occurs, we looked at the aviation industry because that's a great model to see, when there is an accident or anything else, the people who are studying it really study it and understand the root causes. They develop action plans, they have systems in place.

And I think that's a really good place to start for physicians and providers is, if we look at problems that occur—and it may not be even in our own institution, but around the state or other places—what happens, what works, and what is it that needs to be put in place to be able to safeguard our patients overall. Because the odds, I mean, 22 over 100,000, somebody might say, "Well, that's really pretty low." Now, of course, that is way too high, because when we look around the world we know that's too high. And it's increasing, and that's unacceptable. But to an individual person, when they think, "Well, you know, I've not had that many bad outcomes," it can give a false impression that the practice is safe overall.

So I would say that those would be good ways to introduce that concept. The other thing is I have found letting the physician be part of the team and giving room for them to be able to have their own insights, rather than trying to force it on them, I think that also is pretty helpful.

JOHNSON:
Does public health have a role to play in getting a system like this in place?

TOY:
Absolutely. I think public health is so important in this regard because they can see the situation in terms of populations. They can see it in terms of those who have difficulties and in access, whether it be language— One area that is so important for us to be aware of is the racial disparities that our Black patients have in Texas. Three to 3.5 times the maternal mortality rate, and that's regardless of even socioeconomic status. And so we have to be aware that in perhaps our Black patients when they have hypertensive disease, we have to be more vigilant, we have to take it more seriously. When the patient complains of shortness of breath, we have to spend a little bit more time.

And we have to also educate. So I think that's the other side, is education to reduce those risks before a patient becomes pregnant and to be also aware when they have symptoms.

JOHNSON:
How urgent would you say is the need to have more jurisdictions adopt a risk appropriate care model?

TOY:
I think it just needs to be done yesterday. Our maternal mortality rate is through the roof and is a major, major problem. I mean, it is a huge problem overall.

We also have to remember that it's not just deaths. For every maternal death, there's at least 100-150 near misses, and those near misses also cause problems. They are ICU admissions, returned to the operating room. They're costly, and largely these are preventable.

So I think risk appropriate care is so critical to implement and I would just encourage every physician, every provider, every midwife, every nurse, every hospital, and public health official, etc., look into getting this implemented. And I think once it's implemented everyone is on board, because it's working together as a team. So instead of everyone kind of working in their own silos—probably doing a really good job in their individual space—working together is really the secret, and I think it makes it more enjoyable.

It's interesting that over the past decade, and really worse now, the burnout rate among my specialty—which is obstetrics—and also that of our maternal nurses, has had very high burnout rate. That being said, working together as a team and supporting each other has reduced the burnout rate. So we get better quality and less burnout and more enjoyment. And I think for those reasons, I think this whole concept of risk appropriate care is a win-win for everybody.

JOHNSON:
Dr. Lily Lou has spent the last few years serving as chair of the American Academy of Pediatrics' section on neonatal perinatal medicine. She says the nation's maternal mortality rate is embarrassing.

LOU:
I think healthcare works best if all the participants understand how they fit into the overall healthcare environment so they can care for every patient in the setting that matches their individual needs. That means that patients stay as close to home as possible, but with a strategy that every patient receives care in a place where the resources and expertise necessary for their medical situation are readily available, and that higher acuity settings are always available for those who really need them.

Aside from having the right patients in the right places for the care they need, this entails robust and familiar strategies for referral when necessary, and also safe and efficient transport systems to be operating. When this works well, we have smooth transitions of care, good stewardship of resources—both dollars and expertise—we achieve the best outcomes for our patients, and patients and families have the best experience of care.

Risk appropriate care strategies also allow efficiency in education. It's not a one-size-fits-all where every provider needs to learn everything, but education and training are tailored to the practice setting. For example, rural providers may not need to know the latest in congenital heart repair strategies, but perhaps simulation exercises for low-frequency, high-risk processes like resuscitation and pre-transport stabilization are in order.

JOHNSON:
Tell us a little bit more about this. What does it look like?

LOU:
One of the challenges is that people are leaving. There's an out migration of expertise in rural areas. And that's because there are low payment rates, there are low patient volumes, because things just don't happen that often. And so, it's hard to keep talented people in a place where they have a hard time making a living because there aren't very many patients.

So then you have a situation where people are leaving, but you want people to still have access to care in their neighborhoods. So, how do you incentivize people in the higher acuity settings to go out to hospitals, which are actually their competitors, to keep their skills up? One way would be to have staff from the rural hospitals come into the higher acuity settings, have the nurses take care of sicker babies and moms, and then go back and take those skills home. But that takes a commitment of time and resources for the higher-level facilities. Or, you can have experts from higher level facilities go out and teach. But that also takes the generosity of time, and the incentives are not there.

If we can find a way as public health leaders to encourage people and recognize the effort it takes to try to maintain those levels of care in every neighborhood, then we will start to move the needle on that.

JOHNSON:
So all of these ideas, then, in your view, could be part of a risk appropriate care solution?

LOU:
Yes. I think that there needs to be recognition of the time and effort that people who do have the resources and the expertise, that effort that they might put into helping other people. But right now, you're just helping your competitor hospital down the road.

JOHNSON:
And we've heard that, sometimes, that is the issue—the competition and the billing, that the financial end of the process is holding up progress.

LOU:
Exactly. And I think state health officials and public health leaders have a significant role because they're at the table. They are credible with the funders in terms of federal grants and things like that. But they also are in touch with the providers, with the boots on the ground in their neighborhoods, and the people who take care of patients at the bedside. They know exactly where the bottlenecks are, and the barriers their patients face in accessing care, and what they wish they had at their fingertips to take the best care of each patient.

JOHNSON:
What are some of the challenges to achieving equitable risk appropriate care?

LOU:
So some of them are just distance; so, areas that have lower population density. But people still have babies in those areas, they sometimes have problems accessing basic perinatal care, and especially subspecialty perinatal care. So just because they would have to drive long distances, and sometimes there are long wait times for the kinds of services they need. So that takes people who are already potentially challenged just from living in more rural areas, and it adds on the expense of traveling to appointments or having to be transported on an emergency basis when they present with healthcare needs or for delivery.

JOHNSON:
What do you think public health leaders could do to address some of those challenges?

LOU:
One of the things about the pandemic is that we've learned to marshal new techniques like the Project ECHO platform or some of the telehealth methods. But we don't always unite the needs in the rural and underserved communities with where the experts lie. But I think that public health leaders who have a 30,000 foot view of how all the pieces fit together can look at where the connections need to be made.

And one of the really important functions that public health leaders serve is the ability to reach out to various stakeholders who may just be keeping their heads down and working really hard—especially over the last couple of years—and connecting them with others to have conversations about creative and innovative ways to try to share the resources and the understanding of the needs with each other. And then, putting in place the resources necessary to make those things happen.

JOHNSON:
You were a former public health official in Alaska; so, from that perspective, how easy or difficult is it to get involved in promoting a risk appropriate care model in an area where there isn't one?

LOU:
I was a physician health official, so some of my connections came naturally, came easily. But all SHOs would be well served to reach out and develop relationships with clinical leaders in various sectors of healthcare so there's a conduit of real-life input relevant to the strategies you're thinking of or trying to develop. It's also important to share your thinking along the way with the medical community so that they can be well prepared for any changes to come. Existing systems are unwieldy and they don't turn on a dime.

JOHNSON:
We've heard Dr. Toy talk a lot about providers, and you've talked about them, too. What is their role in your view in getting a risk appropriate care system implemented?

LOU:
I think that the reaching out can happen in two directions. So I think public health leaders should reach out and try to establish those directions, those connections. But I think healthcare providers themselves can also make an effort to form relationships with their public health leaders.

Some of the ways that doctors and nurses and social workers can contribute is serving on public health committees or workgroups, or even commenting during public comment periods on proposed rules, changes, or plans. We tend to work long hours and be kind of focused on what we're doing clinically; but I think that as people who understand the system, we also have an obligation to tell people who are a little more distant from the bedside what the problems are.

JOHNSON:
Tell us how public health officials can engage providers to support the risk appropriate care model.

LOU:
We talked a little bit before about rural populations and underserved populations. There was a great recent report from the Advisory Committee on Infant and Maternal Mortality—that's the committee advisory to the Secretary of Health—and the report was called "Making Amends: Recommended Strategies and Actions to Improve the Health and Safety of American Indian and Alaska Native Mothers and Infants". And one of the really great things they did in creating this report and doing this work was to include American Indian and Alaska Native community members in the discussion and they held the meeting in a geographic location that was relevant to those populations—I think it was in Shakopee, Minnesota. And that was the first time it wasn't just at their headquarters.

And that work highlighted some things that were obvious, but also some things that were a little bit surprising. They highlighted the importance of recognizing the pathways that led to a lot of the disparities, including some of the historical traumas, and also the cultural strengths in the AI/AN people. They noted the supreme importance of words and language, and the impact of racism on health, the contribution of sub-optimal living conditions, the valuation of women, and, of course, barriers to accessing care. So this was much more impactful when it came out of the mouths of the stakeholders and the consumers of these services themselves, rather than from tables and data.

JOHNSON:
Is that information powerful enough to get people off the sidelines, do you think?

LOU:
I hope so. I think that's one of the important actions that was taken in that move from awareness of disparities to concrete actions to make it different. And I really think that helping the groups that are most challenged will float all the boats. So these are not things that will be wasted on one population or one neighborhood, but improving those systems will help all the systems.

JOHNSON:
How do you feel about the future of the risk appropriate care model?

LOU:
I think there's been a lot of discussion over the past few years about this. There's a report that should come out soon from the AAP on national standards for neonatal care. Similar things are happening in the OB world as we learn more about risk appropriate maternal care. And ultimately, we all want efficient systems that give each patient the care that they need without having low acuity patients in high acuity beds, so that there's kind of a waste of those resources by occupying them by people who don't need those.

So as these publications come out, as the data comes out, people will gradually learn—through tools like LOCATe from the CDC, or the site visit strategies that are kind of modeled on the surgery trauma center site visits—how to assess what their level of care is, what the education should be for them to maintain that level of expertise, and how they intercalate with other levels of care so that patients can be sent to or move to the places where the most appropriate care is provided.

And that will lead to better stewardship, greater job satisfaction for the people who gravitate towards the different levels because that's the kind of care they like to provide. And the end goal is the best experience of care and the best outcomes for all patients.

JOHNSON:
Thank you for listening to Public Health Review.

If you liked the podcast, please share it with your colleagues on social media. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that address again: P-R at A-S-T-H-O dot org. You can also follow us using the Follow button on your favorite podcast player.

Also, stay up to date on everything happening at ASTHO by tuning in every morning for Public Health Review Morning Edition. We cover news like this every day. Look for the link in the show notes and let us know what you think.

This podcast is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.