Geisinger’s Holistic Maternal Care Model Improves Healthcare Experience

May 10, 2022 - Over the past century, the maternal care model has grown to be somewhat standardized from patient to patient. A birthing person becomes pregnant and has periodic visits with her OBGYN, and once the baby is born, the healthcare experience filters into the pediatrician.

But that care model assumes a healthy pregnancy and few social determinants of health. With one look at the US maternal mortality rate, which is the worst in the developed world, it is clear that some birthing people are falling through the cracks.

Between 2007 and 2016, 7 percent of people who gave birth in a hospital had a substance use disorder diagnosis, according to the National Partnership for Women and Families. Many of these women can’t access the maternity and recovery care they need or access the social services that would make it easier for them to have good birthing outcomes.

Some women are missing that advocate to make the patient-provider interaction easier. Despite mounting evidence suggesting the benefits of a doula or midwife by the side of the pregnant person, the American College of Nurse-Midwives reports that only about 9 percent of all US births have a midwife present.

Geisinger Health System knows that maternal healthcare goes beyond the provider and the patient. Patient needs reach further than clinical symptoms, and providing holistic, wraparound care will be vital in supporting a good patient experience.

Through two programs, one tailored for pregnant people with substance use disorder and another for midwives, the Pennsylvania-based payvider is working on expanding healthcare access options for expecting moms with unique medical needs.

Free2BMom program connects struggling people with care

The Free2BMom program from Geisinger supplements the organization’s existing maternity options through supporting social work, according to Valerie Andreoli, the program’s caseworker. The program sets out to make SUD treatment as stigma-free as possible while adding SDOH screening and referrals to make it easier for the parent and baby to thrive during pregnancy and beyond.

“The biggest challenge for pregnant women who are struggling with substance use disorder, or any substances we take on our program, is the stereotype and the stigma behind addiction,” Andreoli told PatientEngagementHIT in an interview. “It's hard enough for people to be willing to go into treatment when they're not pregnant. But yet it's harder for women to seek that help that they need.”

The Free2BMom team also includes a certified recovery specialist who works with Andreoli to ensure patients get all of the help they need. The CRS is mainly in charge of the recovery aspect of the program, Andreoli said, connecting patients with medical services and medication-assisted treatment (MAT).

The other half of the program focuses on the social determinants of health challenges pregnant people with SUD might experience, like housing issues, limited transportation, or employment options.

Once Andreoli and her CRS colleague receive a patient referral from some social service or clinician, they meet with the patient to learn about those specific needs.

“We meet them where they're at, if it's at Dunkin’ Donuts or their home, or if they're at the clinic at the hospital getting like their OB appointment, we'll meet them to fill out the enrollment paper,” Andreoli explained. “They sign the consent and then they sign the community partner list. We give them a copy of that, so they know what community partners we actually work with.”

That intake process includes an SDOH screening, an assessment for drug and alcohol counseling, and a screening for needed baby items. From there, it’s an ongoing process of assessing and reassessing Free2BMom participants about how their challenges have evolved and how Andreoli and her team can help them.

The program relies on strong community partners, Andreoli added. Free2BMom has inroads with a baby pantry, where parents get can clothes and diapers for the baby, and Cribs for Kids, which helps them set up a space for the baby.

Once the baby is born, Free2BMom care expands to the child. Andreoli said the program prioritizes getting kids to key developmental milestones, for which Free2BMom relies on partnerships with Early Head Start and Early Intervention.

“Two years down the road, we prepare families for discharge,” Andreoli said. “Some moms have a hard time with it because sometimes we're the only support they have. We prepare them for discharge a couple of months prior. Then I and the CRS will do one final home visit with them, close them out, and make sure they have all the community resources that they need. If they need to be hooked up with anything else, then I'll put in referrals for them.”

If that sounds like a lot of work, it’s because it is. Andreoli said she and her team need to be masters in time management and judicious about balancing home visits, community visits, and clinic visits. She’ll plan one consult in the same neighborhood as her next, she offered as an example.

“It's basically on their schedule too. Because they have appointments, they have other kids who might be in school,” Andreoli said, noting that she usually plans visits at the start of the workweek. “Again, it's trying to be as flexible as you possibly can, with a lot of good time management skills.”

Tapping midwives for patient-centered maternity care

Geisinger’s wraparound maternity care also prioritizes the use of midwives, who are central to women’s health and reproductive healthcare.

“Of course, we're most notable for delivery of care for the pregnant women throughout their antepartum state, during labor and delivery, and postpartum,” Karen Carbaugh, Geisinger’s chief midwife, said during the phone interview. “But we also can provide care for women of various age ranges, from teenagers who desire birth control, women who just need routine annual exams, women who are in their later stages of life who just need annual exams, or are postmenopausal for treatment.”

Midwives can reduce the risk of pregnancy complications, according to 2019 research from UW Medicine, potentially because of their role in patient advocacy and patient-centered care.

“One of the most important things is, as midwives, we develop a bond with our patients,” Carbaugh pointed out. “Most specifically, pregnant women like to have that bond with their providers so that they don't feel like a number. They feel like they have a voice.”

Midwives are person-focused healthcare providers who are instrumental in patient communication. Using shared decision-making, midwives can help guide patients through their pregnancy care choices and then advocate for the patient throughout all clinical encounters.

“We are there to help guide the mom and her family through her pregnancy process,” Carbaugh added. “Identifying those situations, comorbidities that may impact her delivery down the road or her potential care. We work with them to facilitate the appropriate follow-up therapies that they may need.”

Geisinger’s midwife program is notable because it also seeks to expand patient access to care in a state with deeply rural areas. Throughout parts of Pennsylvania, the use of midwives is common, but birthing people aren’t accessing them through a formal healthcare provider; they are lay midwives who are treating those in highly remote areas, like those inhabited by Amish people.

Geisinger works to fill the clinical quality gap through deep community partnership and education, Carbaugh said.

“Lay midwives come in for an educational opportunity that is presented by our midwives, and they recognize the comorbidities that can occur with any type of a pregnant wound during the laboring process,” she explained.

Trust has been instrumental in that partnership, Carbaugh added. Suppose a patient in a highly remote area being treated by a lay midwife experiences a life-threatening birthing injury or complication. In that case, lay midwives trust Geisinger providers to treat their patients.

That’s come from a long road of community trust-building, Carbaugh said, and now it’s going both ways. Geisinger is beginning to recognize the know-how and expertise in their lay midwife partners, too.

But as Carbaugh and her midwife colleagues look to fill the care access gap, she said better public education about midwives will be key. Healthcare organizations need to help midwives market exactly what they can do for patients, from working with pregnant people to promoting access to birth control to guiding patients through menopause.

“As we become more prevalent within the community, we're identified and desired more frequently,” Carbaugh stated.

The road ahead of wraparound maternal healthcare

Geisinger’s programs aren’t perfect, Carbaugh and Andreoli both agreed. For one thing, both Free2BMom and the midwifery program have limited resources to facilitate care coordination, even though both know many of their patients could benefit from that wraparound care.

“Sometimes we may not be aware that they're in the Free2BMom program, so it makes things a little bit difficult there too,” Carbaugh explained.

“I almost want to say we’re looking towards a potential nurse navigator who can help navigate between the roles and the responsibilities to assure that everybody is continuing to be focused on their patients,” she added. “Whether they're a Free2BMom patient, whether they're a Healthy Beginnings patient, to assure that we're all working together as one for the betterment of the patient.”

After all, midwives do serve a unique role in the maternal healthcare team, and Carbaugh said there’s great potential for them to supplement the care that Andreoli and her team deliver through Free2BMom.

“The empathy that we can provide for these moms who have a substance abuse history, who are facing some ongoing issues. Whether it be with career, with transportation, with babysitters,” Carbaugh pointed out. “Our support and encouragement of them to continue to dredge forward, and to try to see the light at the end of the tunnel, and that we're all here to help you go a long way.”

In the interim, Carbaugh and Andreoli said they plan to start doing some of that coordination themselves, but Andreoli stressed that it’s going to rely on building deep patient trust. In order to learn more about the resources a patient accesses during her pregnancy requires someone like Andreoli to ask more probing questions, and she and Carbaugh both acknowledged the populations they work with aren’t always trusting of medical systems.

“It not only comes from us, but it comes from the patients as well. And some patients don't say that they have a midwife or don't say they're part of Free2BMom. But it's building that trust enough for them to share that with me,” Andreoli concluded.