Beyond Birth: Matters of the Heart With Orlando Health

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Tom Haederle

While the impending arrival of a new baby is an occasion for joy, pregnancy is also a major stressor on a pregnant person's body. Cardiovascular conditions are one of the most prevalent complications of pregnancy and one of the leading causes of maternal mortality.

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Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this podcast, the AHA’s Julia Resnick, director of Strategic Initiatives, explores how Orlando Health is reaching outside its walls to create the conditions for a heart healthy pregnancy and postpartum for new parents.

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Chinedu Nwabuobi, M.D.

My family and I moved from Nigeria when I was 16. And I always tell people this, which is, you know, growing up, unlike in the United States where I tend to see a lot of joy surrounding pregnancy, surrounding births. I grew up in a place where when a woman was pregnant, there was joy associated with it. But when it got closer to the time for delivery, there was a lot of fear.

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Chinedu Nwabuobi, M.D.

There was a lot of uncertainty. There was a lot of prayer groups being brought together to pray that a woman makes it out alive. I lost my lovely aunt while she was having her seventh child from postpartum hemorrhage, which was very devastating. A lot of people in the U.S., when they think of pregnancy, they obviously, you know, most times think about how I'm going to go have the baby, come back home.

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Chinedu Nwabuobi, M.D.

But the truth is that, unfortunately, anybody can lose their life in the pregnancy.

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Julia Resnick

That was Dr. Chinedu Nwabuobi, grounding us in the medical risks inherently involved in pregnancy. He is a maternal fetal medicine physician at Orlando Health Women's Institute Center for Maternal Fetal Medicine. I'm Julia Resnick, director of Strategic Initiatives at the American Hospital Association. And this is Beyond Birth in advancing Health Podcast. Today, we'll be focusing on matters of the heart.

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Julia Resnick

Not only is February Valentine's Day, it is also Heart Health Month, a month dedicated to raising awareness of heart, health and cardiovascular conditions. Today, we will be exploring cardiovascular health during and after pregnancy and what hospitals can do to help create the conditions for a heart healthy pregnancy. So why heart health? Pregnancy is a major stressor on the body, and particularly on the heart - complicating up to four in 100 pregnancies.

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Julia Resnick

Cardiovascular issues continue to be one of the most common causes of maternal morbidity and mortality. One-in-three pregnancy related deaths in the U.S. are due to cardiovascular problems, and people who are black, American, Indian or Alaska Native are at higher risk of heart conditions during pregnancy and have a much higher risk of dying during pregnancy or soon after.

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Julia Resnick

Hospitals know that creating the conditions for a heart, healthy pregnancy and postpartum period is key to improving outcomes. In this podcast, we'll be exploring how Orlando Health is reaching outside its walls to meet the needs of moms who are at risk of experiencing cardiovascular issues. You'll hear more from Dr. Nwabuobi, as well as Dr. Lori Boardman, chief quality officer at Orlando Health

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Julia Resnick

Winnie Palmer Hospital for Women and Babies. Peggy Burgess, founder and CEO of the Center for Change and Crystal Wilson, a new mom who participated in Orlando Health's telehealth hypertension program after giving birth. We'll start with Dr. Boardman’s overview of Winnie Palmer Hospital and the population they serve.

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Lori Boardman, M.D.

Winnie Palmer is really sort of almost iconic nationwide, and it has been that way because of generally the large volume of patients that we take care of here. So in the last fiscal year of full data that we have, we delivered 14,550 patients under one roof. We take care of 142 neonatal beds and their occupancy runs around 80 to 90%.

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Lori Boardman, M.D.

So not only do we have a large patient population of persons who are delivering, but we have a lot of sick babies as well. So we have a lot of babies born early and a lot of babies with complex needs. So Winnie Palmer Hospital is a standalone women's hospital, it's an 11 story building. It houses a Labor floor of about 28 delivery rooms and houses, three floors for postpartum care.

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Lori Boardman, M.D.

We have a floor dedicated to the NICU which again is large, and you get lost wandering around it because of the number of beds and pods involved. We have a triage area for taking care of those patients coming in with emergency needs and all the volumes in these sites are quite high.

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Julia Resnick

Dr. Nwabuobi who you heard from at the beginning, specializes in perinatal cardiovascular health. I spoke with him about the prevalence of heart conditions during and after pregnancy.

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Chinedu Nwabuobi, M.D.

es, and this is covering from: 2007

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Chinedu Nwabuobi, M.D.

And the top cause of that turns out to be cardiovascular disease, about 26.5%. So on a national scale, that is already quite an alarming number. The volume continues to increase. But when you look, we are talking about chronic hypertension, which is a cardiovascular complication. You're looking at about 8.6% in our African-American patients. You look at about 4.7% Hispanic patients and is Hispanic of any race.

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Chinedu Nwabuobi, M.D.

And you're looking at about 6.2% in all non-Hispanic white. And then when you bring in something like actual preexisting cardiac disease, about 5.1% in our African-American patients, let me just say black patients as a as a whole, non-Hispanic blacks by about 3.9% in our non-Hispanic white and about 3.1% in our Hispanic patients of any race. So, again, these are numbers that continue to rise over time, but it's both a local and a national problem that needs all hands on deck.

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Julia Resnick, M.D.

And you kind of touched on this, but are there certain populations that are particularly at risk for both maternal mortality and maternal morbidity due to cardiovascular issues?

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Chinedu Nwabuobi, M.D.

I'm glad some of these things are starting to get national attention as far as like the media is concerned. But this is something that continues to marvel a lot of us, which is the fact that even among the black race, when you correct for education, where you correct for socioeconomic status, that a patient who is of a black race continues to have up to fourfold the amount of risk of maternal mortality, including cardiovascular causes of death when compared to the other races.

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Chinedu Nwabuobi, M.D.

So that's definitely a fact. Something else that we continue to see to be a population that is at risk for some of these complications are women who are aged 35 and above. You know, I tell a lot of my patients, I joke with them when I say, you know, well, age is just a number. But in this case, it's not just the number because, as you know, your age goes beyond just having knee pain or aches, getting out of the bed

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Chinedu Nwabuobi, M.D.

now. It really actually counts your chances of making it out of your pregnancy healthy, and the baby, you know, healthy as well. So age is a factor that we need to pay close attention to. And then there's also the factor of patients who do not have prenatal care and I think the angle of looking at this is probably thinking about access to care.

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Chinedu Nwabuobi, M.D.

Most people do not just ignore care completely. There are several factors that limit them deciding that they will get up, go see a physician, go see a midwife, go see whoever that provides their prenatal care to get care beyond the fact that they are noncompliant. Right. Some people have issues with transportation. Some people do not even have a place to live.

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Chinedu Nwabuobi, M.D.

Some people are probably a juggling two or three jobs to make ends meet and not able to make that appointment. Sometimes we do not have the best clinic hours to actually accommodate all of these patients with some of the things going on in their lives. It's very multifactor, but again, it comes down to that lack of access. So these three populations with the black race, the age and limited access to care can definitely exacerbate the issue of cardiovascular complications and pregnancy.

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Julia Resnick

It is clear that some people are more at risk of experiencing cardiovascular issues during pregnancy than others. To target their efforts and address those inequitable birth outcomes, Dr. Boardman and her team dug into the data.

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Lori Boardman, M.D.

There's a lot of disparities and we can talk about a number of them that we see in our data. This just mimics nationwide data, and we know that black women in particular are disproportionately affected by severe maternal morbidity and mortality. And we know that they, no matter what their background is, no matter how much education they've gotten, no matter how much money they make or where they live, they all have a similar pattern of unfortunately, being more likely to have a severe maternal morbidity event in their lives.

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Lori Boardman, M.D.

And you see it on television. Serena Williams can't get it done. Nobody can. So what we did and what I've done for the last decade is, is create some dashboards that really allow us to look at different things. So we have a whole set of dashboards around severe maternal morbidity. One is just outlining and knowing what those severe maternal morbidity events are.

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Lori Boardman, M.D.

So our most common forms of severe maternal morbidity tend to be sepsis, which is a severe infection, tend to be renal failure, and then also tend to be more of those hemorrhage events. So we do follow those. And the biggest one probably is now hypertension or hypertension related causes. So we look for those rates and we are able to calculate that.

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Lori Boardman, M.D.

But we also want to have a way to identify those patients who are at greater risk for having a severe maternal morbidity event. And one of those is to use something called the comorbidity index. So we've been able to collect that information at the time of delivery so we have a good idea what our patients are struggling with.

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Lori Boardman, M.D.

For example, if we look at the black population, that population comes in with a preexisting history of anemia and almost half of those patients. We know there's opportunity there to follow them more closely. We know that when we looked at our patients coming back after they've been here for delivery to be readmitted to the hospital, the most common cause was hypertensive disorders.

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Lori Boardman, M.D.

So using that as a way to move forward, we also knew we were in the middle of a pandemic and a lot of people weren't coming into the hospitals or going to practices. So we use the telehealth platform to have a program that we established while those patients were in the hospital, they delivered. If they had any kind of hypertension problem or they had even had a history of chronic hypertension before they came in, we wanted to follow them

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Lori Boardman, M.D.

when they went home. It did really well. And then a lot of providers were, well, skeptical of the program. But then when they saw the results, everybody jumped on board. So at this point, we have everybody involved with our postpartum hypertension program. That means that when those patients go home, we want them to be teed up as much as we can to go home in a healthy way.

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Lori Boardman, M.D.

So the institution started doing something called "meds to beds" so that you would go home with your prescription in hand. If you had to be on something for your blood pressure, you were given it so that you didn't have to go to a pharmacy and try to get it delivered to you or have to go through anything. So most patients were able to go home with a prescription.

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Lori Boardman, M.D.

We recruited them before they left the hospital. Our retention rate from recruitment was over 90%. So every month we had about 300 patients and we would have close to almost all of them would be in the program. Initially, we wanted to do day two after you got home and then a day five visit, because most of our readmissions were in that first week.

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Lori Boardman, M.D.

But we found out very quickly that we needed to do one the day after you went home. So we caught more people doing that. We were able to engage with them in the platform like we're using. So I'm looking at you and we're having a conversation. We use the platform to not only ask them about their blood pressure, but also to ask some other related questions.

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Lori Boardman, M.D.

We screened all the women for depression and anxiety. We screened everybody for social determinants of health and social drivers of health and we also talked a lot about breastfeeding because we know that black women are much less likely to breastfeed, so to provide them the support to do that before the patient went home. Everybody went home with a cough and a monitor and then they were given education about how to know when there's a sign or symptom that you're having that needs to be addressed.

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Lori Boardman, M.D.

Who to call. If the blood pressure was sort of in the middle range, you would call the provider. If it wasn't, they would come to the hospital. And for most patients, and particularly for those patients that struggle probably with social support and transportation, they couldn't believe that they could do all of this in their kitchen or their bedroom or wherever they wanted to be.

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Lori Boardman, M.D.

And it just took off that load of having to worry about who's going to drive you. We could even do some of those social determinants, social drivers of health like hunger and food, getting them delivered directly from one of our community partners and they can drive that stuff to their home so they can have fresh vegetables and other perishable and nonperishable items.

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Lori Boardman, M.D.

So when I would even be recruiting them, people would cry. They just couldn't believe that this kind of program would exist.

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SFX

Baby cooing

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Julia Resnick

Crystal Wilson delivered her third child at Winnie Palmer last year. During the course of her pregnancy, she learned that she had previously undiagnosed cardiovascular issues. After giving birth, her provider knew her heart was at risk for future complications. Enter the perinatal hypertension telehealth program.

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Crystal Wilson

At the hospital in the recovery room, I met with this woman. I can't remember her name and she gave me like a monitor for my blood pressure and a

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Crystal Wilson

scale and

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Crystal Wilson

she asked me if I wanted to be involved with some of the programs. And I'm like, You know what? It's not going to hurt. You know, it can do nothing but help me. There were a bunch of programs available for me. I call it counseling. That for me was a really good coping mechanism. So I heard from different moms, you know, building relationships.

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Crystal Wilson

So I think it was a really, really good program. The support group was

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Crystal Wilson

a huge thing.

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Crystal Wilson

The counseling, the meeting of the moms and all of that. Try to reduce stress anxiety, which also affects your blood pressure.

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Julia Resnick

The health care workers at Winnie Palmer couldn't accomplish this alone. They partnered with a local organization run by our guest, Peggy Burgess. Peggy shared the origin story of her organization.

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Peggy Burgess

started Center for Change in: 2003

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Peggy Burgess

And what it was about was educating people who had less resources than she had to find out where they can go for treatment, who they could talk to, what they can do to improve their health, and trying to give her just a sense of security or control.

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Julia Resnick

Out of this original program grew The Center for Change, an organization that leverages community health workers and offers health coaching and self-management courses and chronic disease, amongst other opportunities to improve health.

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Peggy Burgess

What we were actually doing was - and I'm so glad Orlando Health had the program designed where they had the bus available. They had the clinicians available and they were part of the program was requiring them to make sure that they go it. And for our end, it was no more than providing that extra push, that extra check in with them to see, are you doing okay?

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Peggy Burgess

Are you following through? Why haven't you gone to check on this or that really doesn't sound normal to me. I would suggest that you check on this. You'll be surprised at the number of young mothers who are unaware of signs and symptoms and would say, Well, I have an appointment in three weeks. No. If you have swelling to this extent and is moving up your legs, something is wrong

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Peggy Burgess

now. You need to have that checked. Sometimes just that motherly push is enough to say, okay, okay, I'll go. And they know that we're going to call back because we are their accountability partner in a way, because it is our responsibility to make sure that not only are we educating, but we're there for support and we're also there to listen.

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Peggy Burgess

One of the biggest things that the community health workers - and we train them to do - is please listen to what your client or your patient is saying to you. Listen, because they will give you all the clues that you need to help them. I love the program that we're working with with Orlando Health now, But if it was my goal, my goal would be for it to continue to grow so that not just a few of the mothers that are high risk, but all mothers that are high risk would have access to this.

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Julia Resnick

The Center for Change wasn't the only community partner involved in this program. Dr. Boardman spoke to the other groups that have been instrumental in providing holistic wraparound services for new moms.

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Lori Boardman, M.D.

one grant, we enrolled about: 1200

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Lori Boardman, M.D.

They had touched 500 patients and their families with food boxes. They were 90 days of food boxes being delivered every other week. For families that really needed it continued. And then another group that we worked with, we've worked with a number of folks was Christine Certain who a perinatal licensed mental health counselor. She's been doing group counseling for patients who screened positive for the depression or anxiety, which is a very common side effect of pregnancy.

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Lori Boardman, M.D.

And in the postpartum period, it manifests itself. But you can see it throughout pregnancy.

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Julia Resnick

Addressing the medical, social and emotional needs of new moms helps create an environment where they and their babies can thrive. And the perinatal hypertension telehealth program has been incredibly successful in moving the needle on pregnancy and postpartum outcomes. Dr. Boardman shared the impact that it has had on their patient population.

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Lori Boardman, M.D.

So when you look at participation from patients that have known hypertensive disorders, we recommend coming in for a visit in about 7 to 10 days. White women and Hispanic women, about 80% of those patients will go to them. About 25% of black patients will go to those visits. With the virtual visit platform, everybody participated in excess of 70 to 75%.

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Lori Boardman, M.D.

So we didn't see those disparities anymore. And if a patient completed at least one of those two visits, the readmission rate was about half of what it was for patients who didn't do that. It's now become embedded in Winnie Palmer. It's part of what we do. It's not a pilot, it's not a study. It's really how we treat our patients.

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Lori Boardman, M.D.

That's gone exceedingly well.

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Julia Resnick

Everyone's needs are different. To get the best outcomes and reduce risk, hospitals need to design care with and around patients and create systems that make it easier for new moms to care for themselves and their babies. We'll wrap up with some closing thoughts from doctors Nwabuobi and Boardman.

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Chinedu Nwabuobi, M.D.

Like I said earlier, pregnancy being kind of a stressor can mask this. So just be on top of your care, be very involved, be an advocate for yourself, speak up, ask questions. Those symptoms that you've read online, you've seen on Tick-Tock that you consider are normal should not be normal until it has been completely addressed by your OB provider. To make sure we care for women more before they become pregnant so that when they become pregnant, there's already that understanding of what the risk is, hopefully we've mitigated it, and how we can make for the best pregnancy outcomes of it.

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Lori Boardman, M.D.

I know from thinking about even creating programs and all this kind of stuff, having the end user be involved in the conversation, and I think listening to our patients learn from our patients and then when you start to implement your whatever you're deciding they're going to do, make sure that it aligns with what they want to do because otherwise we're never going to be successful.

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Lori Boardman

And I think they know better than we know what's going to work, for them and often for their communities.

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Julia Resnick

Heart Month can be a catalyst for health care organizations to reimagine what it takes to create the conditions for a heart healthy pregnancy. And that will require going beyond the hospital walls to engage patients and collaborate with stakeholders who all share the same goal, healthy moms and healthy babies. By designing pregnancy care around patient needs, recognizing who is at risk of complications and reducing barriers to support,

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Julia Resnick

hospitals can make progress towards reducing maternal morbidity and mortality. A big thank you to all of our speakers: Lori Boardman, Chinedu, Nwabuobi, Peggy Burgess and Crystal Wilson. I appreciate everything you do to support the health of your patients and community members. For more resources on improving maternal health visit www.aha.org/betterhealthformothersandbabies

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Julia Resnick

Thank you for tuning in to this episode of Beyond Birth and Advancing Health Podcast. If you missed any of our previous podcasts, you can find them wherever you listen to your podcasts and please subscribe to the Advancing Health Channel. We'll see you next time.