American cities face stubbornly large racial disparities in infant mortality, pre-term and low-birthweight births along with unacceptable rates of maternal mortality. Researchers have identified stress from issues such as substance use disorders, housing insecurity and domestic violence as key contributors to poor birth outcomes. Can multi-sector initiatives to address these social factors have an impact on maternal and infant outcomes? Los Angeles County is engaged in a research project to measure the impact of such a program.
The Robert Wood Johnson Foundation’s System for Action program examines the impact of different types of programs, policies and health-related systems on health, equity and well-being. It sponsored a recent webinar delving into a research study just getting under way to assess the impact of Los Angeles Maternity Assessment Management Access and Service (MAMA) program, a multi-sector initiative that seeks to address the constellation of social factors that contribute to adverse maternal and infant outcomes, including housing instability, food insecurity, untreated mental health conditions, domestic violence and substance abuse.
A research team led by Los Angeles County will test the effectiveness of the program’s four major components: (1) a health home care management model; (2) peer and community support; (3) flexible funding for non-medical services; and (4) an advanced health information technology platform. The team will partner with the University of Southern California Children’s Data Network, Public Health Foundation Enterprises, and the county offices for child protection and probation to conduct the study.
Erin Saleeby, M.D., M.P.H., director of Women’s Health Programs and Innovations for the Los Angeles County Department of Health Services (DHS), said that Los Angeles sees low-birthweight and preterm births that are much higher than the national average. Approximately 95 percent of births in DHS facilities are covered by Medicaid, and the rates of pre-term and low-birthweight babies are twice as high as all births in the county.
The public health system sees women with many co-morbidities and issues related to access to care. Comparing the three DHS hospitals to state and national averages, there are staggering disparities.
As a response to seeing these statistics in its hospitals, she said, in late 2014 DHS launched MAMA’s Neighborhood to partner with community agencies to build a neighborhood network of care for pregnant women and their families. This effort focuses on partnerships throughout the community for patient-centered care. Partnered agencies work with MAMA’s to integrate community services, such as food, housing security, mental health, perinatal childbirth education and breastfeeding.
Saleeby said there has been research on different social stressors that combine to what is called “allostatic load” that contributes to poor birth outcomes. For instance, rates of anxiety and depression are much higher in L.A.’s African-American community than nationwide or in Los Angeles County generally. “Most aren’t things we are usually addressing in standard medical or prenatal care,” she noted. That forced DHS to think about these upstream social drivers. The Los Angeles MAMA program is part of a nationwide HHS-funded Strong Start initiative. The goal is to decrease pre-term and low-birthweight babies by decreasing maternal stress. That required doing a better job of systematically screening expectant mothers for social needs and activating other parts of the safety net. “We realized we were not aligning service provision with those specifics stressors in mind,” she said.
The MAMA effort involved taking a comprehensive and coordinated approach to patient needs as part of a formal care plan. “We stepped back and disrupted and redesigned system that they are eligible for, putting them in the driver’s seat. They connected with neighborhood agencies to address social determinants of health that had been inconsistently addressed.
DHS reconsidered its approach to prenatal visits, shifting from a top-down hierarchical model focused on the physician to organizing patient time with various care team members, telegraphing this physically to patients where possible by redesigning the physical footprint to put community health workers at the front of the clinic, so they are among the first people patients see after registration, rather than at a cubby hole at the back of the clinic.
The effort also involves deploying community health workers as care coordinators, as well as social workers, dieticians, health educators and others participating and taking a multidisciplinary approach. “We created unit-based teams to create work flows that make sense and that leverage neighborhood networks,” she said, adding that they are trying to address the “5,000-hour challenge,” referring to the 5,000 hours per year patients do not spend with providers.
The team developed a comprehensive tool that brings together measures that have been validated to best characterize these social determinants of health needs. They are combined into a global stress score to identify patients dealing with high, medium and low stress. The resulting needs assessment generates a “prescription” for geocoded entities close to their home to better activate care.
During the webinar, Saleeby was asked about barriers they ran into in establishing the program. She said there was lots of legwork required in activating the network and coming up with affiliation agreements between partners to do cross-sector engagement is a lot of investment of time and relationship building. “We have done a lot of neighborhood engagement activities to try to bridge those gaps,” she said. “LA County DHS hasn’t necessarily been the best neighborhood partner in decades past. There was and still are some historic challenges to overcome. Some of that speaks to the fact that this is a long-haul program. It takes incremental improvement and deepening of relationships.”
She also noted that healthcare providers and payers are very interested in this type of program because the return on investment is very good. “You can spend a lot of money upfront to prevent a pre-term birth, because pre-term births are billions of dollars to payers every year,” Saleeby noted.” The return on investment is good if you can make an impact. That said, it does take a capitated model or value-based payment, because there are a lot of non-direct services and IT systems to link people as well as nonclinical or paraprofessional service providers we utilize such as community health workers to do the work. It does take some sort of capitated structure or other bundled payment so you have the freedom in a health system to use those dollars to support a more team-based and collaborative approach. But the ROI is pretty good when you are looking at an outcome that is this costly.”