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Designing Pregnancy Care to Meet the Needs of Hispanic Families
October is National Hispanic Heritage Month. In this conversation, Jennifer Cohen, M.D., medical director of Newborn/Infant Intensive Care Unit at Children’s Hospital of Philadelphia, King of Prussia, and Katie Costantini, director of maternal care services at Chester County Hospital, discuss the barriers that can affect maternal care in Hispanic populations, and how deploying bilingual volunteers provided the opportunity to learn what worked and what could be be improved.
Transcript
Tom Haederle
Chester County Hospital in suburban Philadelphia tells a story that most hospitals and health systems can relate to. It was clear to care providers that disparate outcomes for patients were driven by barriers to care, such as food insecurity and transportation issues. The outcomes gap was especially noticeable in its Ob-Gyn clinic, which serves uninsured and underinsured women, most of whom self-identify as Hispanic.
::Tom Haederle
So the hospital, a member of Penn Medicine, took steps to close that gap. And it all began with dialog.
::Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In observance of National Hispanic Heritage Month, today's podcast, hosted by Julia Resnick, director of Strategic initiatives with the AHA, takes a look at how bilingual volunteers fanned out across Chester County Hospital's service area to hear firsthand how maternal and infant support services could be improved.
::Tom Haederle
And now to Julia.
::Julia Resnick
Jen, Katie, thank you so much for joining me today. For our listeners at home, I'd love to start by having each of you introduce yourselves. So can you talk a little bit about your professional background and your areas of interest and expertise?
::Jennifer Cohen, M.D.
Sure. Thanks so much for having us on. Really appreciate the opportunity. So my name is Jen Cohen. I'm the medical director of the CHOP NICU in King of Prussia currently. And, previously, my role at Penn Medicine, Chester County, was the medical director of the NICU there, as well as medical director of the maternal child service line for quality and safety.
::Julia Resnick
How about you, Katie?
::Katie Costantini
Hi, Julia. Thank you so much for having us today. Like Dr. Cohen said, my name is Katie Costantini, and I am the director of maternal child services at Chester County Hospital. I am a nurse by background and I have had a variety of leadership and clinical roles in Penn Medicine over the last 20 years.
::Julia Resnick
Wonderful. So tell me a little bit about Chester County Hospital and the community you serve. Particularly, what are some of the maternal health challenges, that your community experiences? Katie, why don't you start this one.
::Katie Costantini
the continuum. We have about: ::Katie Costantini
So our Ob-Gyn clinic serves the uninsured and underinsured women of Chester County. In our clinic, about 95% of those patients identify as Hispanic and are primarily Spanish speaking. These patients have a variety of challenges in obtaining health care. Their major challenges are related to transportation barriers as well as food insecurity.
::Julia Resnick
And so then when you're looking at health disparities, both for the pregnant person and the infants, what kind of disparities and outcomes are you seeing for that population?
::Katie Costantini
Some of the disparities that we've seen were a difference in our outcomes, specifically in our postpartum complication rates. So team was feeling that perhaps we had a difference in outcomes. Postpartum infection rates, increase in maternal morbidity and mortality in our Hispanic patients. And so we took an opportunity to go to the data and look at the data and the data confirmed that much.
::Julia Resnick
And I know we've been seeing a lot of headlines recently about people not accessing prenatal care. And that's one of the reasons we're seeing some disparate outcomes. What are you seeing in your community?
::Katie Costantini
We have an interdisciplinary team, many of which are bilingual, actually have developed great relationships with our community. That being said, our patients still struggle to sometimes get to their appointments, right? So some of those transportation barriers that I mentioned, it makes it hard for patients, you know, to schedule a month out when their next appointment is going to be and then to actually be able to go to that appointment.
::Katie Costantini
So we still see that as a major barrier.
::Julia Resnick
That takes us to your efforts on what you're doing to improve outcomes for those Hispanic moms and their babies. So can you talk about the initiative that you're working on?
::Jennifer Cohen, M.D.
As Katie mentioned, we initially perceived through from our staff and our medical team that there perhaps was a difference in outcomes for our Hispanic population. And as part of Penn Medicine, one of our service line goals is to look at health equity and work on disparities across our health system. Really, locally, for us, we focused on our Hispanic population
::Jennifer Cohen, M.D.
given that about over 20% of our births in our Hispanic population and in Chester County. It's a community that we are really dedicated to serving as well. So that really brought us back to the data where we saw that, in fact, there was some disparities in health outcomes when we look specifically at postpartum complications in our moms.
::Jennifer Cohen, M.D.
And what that refers to is, things like postpartum infections as well as postpartum hemorrhage. Our first looked was to look at the data, and then our second pass was really to talk to our staff, including nurses, the medical team, social work, our interpreter services, and certainly all of our women's clinic team members. And what we recognized that we needed to do was really to start looking at our care model.
::Jennifer Cohen, M.D.
And, of course, as important is really to go to the voice of the patient as well, and to make sure that we're understanding where the barriers might lie.
::Julia Resnick
So once you started engaging your patients there, what did you learn from them?
::Jennifer Cohen, M.D.
Our first challenge was really to determine how best to get to that voice. Given that there are some language challenges or some language barriers as well as cultural challenges. So that we could be sure to get honest and accurate answers from our families. So we recognized quickly that our need to engage our patient and family advocacy team, and we're able to partner really well with them so that we could leverage their relationship with families and patients to be able to get really, great truthful answers from our families.
::Jennifer Cohen, M.D.
Our first step with that was to pair volunteers, English and bilingual volunteers, to go interview postpartum moms before discharge to find out from them if they experienced any barriers during their inpatient hospital stay and to review with them whether there were any concerns, whether it was, for medical care or cultural or any other challenges that they may have experienced.
::Jennifer Cohen, M.D.
Those interviews were then followed up a week later with a phone call by the same volunteer team, really to continue that relationship with the patient, as well as to be able to review with them if they had been able to retain the information that was given to them at the time of discharge in terms of postpartum care and any concerns to look for in their postpartum recovery.
::Jennifer Cohen, M.D.
We learned some really important information from those interviews and follow up calls. In the initial interviews that were performed with our volunteers, they reviewed with families and moms how much they retained from the medical information of what to look for, for postpartum concerns. And we found that about 14% of those families could not recall any of the information that was given to them at that time, which was certainly, you know, a concern that was raised for us.
::Jennifer Cohen, M.D.
And we saw that big care gap, right there. Also interesting was, in our follow up calls in a week, we saw that number rise to 38% of families who could not recall any information that had been given to them. So that was a very loud signal to us that we need to really address those communication gaps.
::Katie Costantini
One of the things I'll just add to what Jen shared is the final part of obtaining our patient feedback in this project was recognizing that when you're doing health equity work, you really need to meet patients where they are. And that's not within the four walls of our hospital, right. And so the decision was made to really get pull together a team, a bilingual team that could go out into some of our community churches and meet with some of our Hispanic patients in an area where, you know, they trust the community,
::Katie Costantini
they trust the environment as the final step in obtaining meaningful feedback about how we were performing as a hospital and then what we could do to help improve care for the future for other families. And that was really meaningful, and I think really gave us the actionable items to put a program in place.
::Julia Resnick
So you've gathered all this feedback from your providers, from your patients, from your community members, to all inform the programs that you're putting together. So can you tell me about the program and walk me through what it is and how it works?
::Katie Costantini
So it's really a multifaceted program. There's multiple elements, some that we were able to put in place right away and others that it's been a journey to really put in place to help improve care for our patients. One of the first things we did was partner with the Chester County Food Bank to put a food pantry in place within the hospital, very close to the clinic.
::Katie Costantini
So that way to address some of the food insecurity, when patients come in to their prenatal appointments, if they feel they're not able to access food for themselves or their family, we're able to extend them home from that appointment with a bag of food from that food pantry. We also expanded our in-person interpreter services, as well as added an on call interpreter for circumstances that come up, because one of the biggest "aha" moments for us in obtaining patient feedback was really the impact of having an in-person interpreter versus some type of other technology for interpretation.
::Katie Costantini
So we expanded those hours. We also started offering prenatal tours to our Hispanic patients, so they have an opportunity to see the maternity floor and the department before they come in to have their baby, to help build that trust, because trust came up time and time again in doing these interviews. So to help kind of bridge that gap, we now offer prenatal tours.
::Katie Costantini
They've been very successful. There are often patients out there touring the units with one of our bilingual volunteers. So it's someone that can speak to them in their own language. They feel comfortable, they can ask the questions. They can meet some of the staff members before they come in to have their baby. And then one of the other things we did was increase our social worker hours.
::Katie Costantini
So we traditionally had one social worker covering the service, now we have two full time social workers to really help fill the gap, set up our patients across the continuum with more comprehensive services, not just during the time that they're here to deliver.
::Julia Resnick
That's really wonderful. And Jen had talked about, you know, retaining information when they go home. Have you thought about how you're communicating differently with your patients so that those messages stick?
::Katie Costantini
Yes. So a few things we've done. So we've made sure all of our educational materials are available in Spanish, making sure we're sending information home with patients that actually resonates with them. We also started changing our teaching style. So we learned a lot through this process. In the Hispanic culture it's not so much like a fact-based learning,
::Katie Costantini
it's more of a storytelling and really incorporating the entire family. So, you know, patients shared with us that they were a lot more likely to listen to their mom or grandmother for advice than they were advice coming from a health care provider.
::Julia Resnick
That's wonderful. Really think about how you engage the whole family and that whole circle of support. So it's not just, you know, mom who's responsible, but the whole family. Jen, anything else you want to add about the program?
::Jennifer Cohen, M.D.
Katie alluded to one of the other signals that we saw was food insecurity, and we were able to address that directly with setting up a food pantry, partnering with the Chester County Food Bank. We have a little annex as well up in the NICU, of a food pantry that's a little more accessible to families with longer term stays there.
::Jennifer Cohen, M.D.
And a project that we had started in the NICU, was a pilot of doing more comprehensive screening for social determinants of health and screening all of our families on admission to the NICU. What we saw is, as that project spread throughout the service line, is that our Hispanic population certainly has more food insecurity than we even had recognized initially in our first work.
::Jennifer Cohen, M.D.
So that's something that we're currently able to, you know, really start addressing in in a deeper way. And we have been able to see some impacts in the stories that we've heard from our families, how having that access in a respectful and positive way to be able to help these families from day-to-day.
::Julia Resnick
Wonderful. So let's talk a little more about impact. So you're doing all this really fantastic work thinking about how do you do wraparound services for your patients, but how are you measuring the impact? How do you know you're making progress?
::Jennifer Cohen, M.D.
We have been tracking very carefully our postpartum outcome data and we have seen a really nice trend in a decrease of postpartum complications in our Hispanic maternal population. So from the start of our project where we saw a signal, compared to the rest of the population, we been able to see that decrease by more than half and been able to keep that sustained as well.
::Jennifer Cohen, M.D.
What we have learned in a deeper way is the importance of looking at outcomes by ethnic and racial backgrounds to look for those disparities, because otherwise, if we don't look we won't see the signals and we won't be able to tease out the importance of focusing on a specific population.
::Katie Costantini
The other thing I'll mention just to add to what Jen said, was the other way we know we are doing better is our patients are telling us. So patients who've been here before had a baby with us before are telling us there's a difference in how you're providing care and it has made an impact on us.
::Katie Costantini
And we're telling our friends to come deliver it with you, too.
::Julia Resnick
That is wonderful. I want to thank both of you for taking the time to tell us about this work. But mostly I want to thank you, Jen and Katie, for the work that you do every day to serve the patients in your community. Really making a difference. And I think this is one of those bright lights in the world of maternal health.
::Julia Resnick
And we look forward to being able to share your story more widely with our members and the whole health care field at large. So thank you both so much.
::Katie Costantini
Thank you so much for this opportunity.
::Jennifer Cohen, M.D.
Yeah. Thanks so much.
::Tom Haederle
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