Primary Submission Category: Health equity
Breaking Barriers: Transforming Maternal Health Services Through Community Engagement and Care Coordination
Authors: Jenny Bernard, Jenny Bernard, Victor Carillo, Jose Azar,
Presenting Author: Jazmin Cascante*
Research question: In low-income postpartum patients disproportionately affected by social determinants of health, how does a community-engaged, nurse-led transition of care model, compared to standard postpartum care, affect hospital readmission rates within 30 days post-discharge?
Significance: Maternal health (MH) inequities, primarily driven by social determinants of health (SDoH), significantly contribute to adverse patient outcomes, including the rise in maternal mortality from 20.1 in 2019 to 32.9 in 2021. The First Thirty (FT) program emphasizes the vital role of community partnership in addressing health inequities by enabling patient-centered care, improving MH outcomes, and reducing readmissions. The FT program tackles health disparities by empowering interprofessional healthcare teams to provide comprehensive care, fostering better postpartum outcomes.
Data/methods: A diverse multidisciplinary team implemented innovative care coordination through the FT initiative by implementing the Transition of Care Bundle (TOCB), consisting of care coordination, transportation, medication, follow-up phone calls, and a patient-centered wellness package. This initiative partnered with community-based organizations to address SDoH needs via referrals, health fairs, and educational workshops for underserved communities.
Results: The findings reveal a remarkable decline in the overall readmission rate since the program’s launch, dropping from 7% in 2022 to 2% in 2023 and 1.6% in 2024. Strong community partnerships resulted in a 100% appointment scheduling rate and a 73% attendance rate. This involved 15,140 reminder calls and 1,321 transportation services provided. During the 2023 cohort year, 77% of the patients screened for eligibility were enrolled and received TOCB services. These results strongly reinforce the program’s effectiveness in advancing MH outcomes.