Making an impact

ASCENSION TEAMS RENEW FOCUS ON SUSTAINING THE HEALTH OF COMMUNITIES

Access to safe housing, nutritious food and even transportation can have a significant positive impact on a person’s health and well-being. And being deficient in these areas and other social determinants of health (SDoH) — conditions in the environments where people are born, live, learn, work, play, worship and age — can contribute to health disparities for various communities.

That’s why Ascension’s Community Impact team set a new vision aimed at improving the health of communities and achieving a deeper understanding of who our patients are, where they live and the barriers they face every day.

“By intervening upstream, we have the opportunity to better serve our underserved populations while complementing the clinical work of our care teams,“ said Stacy Garrett-Ray, MD, MPH, MBA, Senior Vice President and Chief Community

The Ascension SE Wisconsin Hospital – St. Joseph Campus team stocks a food pantry to help support expectant and new mothers and their families.

Impact Officer, who leads Ascension’s Community Impact team. “This starts with advancing our ministry’s capabilities, aligning our culture to better identify social determinants of health, and increasing access to high-quality healthcare.”

LISTENING TO THOSE WE SERVE

This new vision is already in motion and helping one of our most vulnerable populations — pregnant and postpartum women. Expectant women in the U.S. face some of the highest severe maternal morbidities (SMM) rates compared with other developed countries. And SMM rates for Black, non-Hispanic women are almost three times higher than those for white women.

“Across the country, we are seeing wide disparities when it comes to maternal health,” said Allison McNeil, MSN, CNM, Senior Director - Community Impact, Ascension. “To narrow this gap, we launched the Maternal Health Social Systems Initiative in 2019. Our initiative focuses on getting expectant and new moms to their appointments to ensure they have access to timely care. Research shows that early care intervention in pregnancy can optimize outcomes for both mother and baby.”

The initiative applied Ascension’s Social Response Framework to first identify what systemic social barriers expectant women face when it comes to getting to their prenatal appointments. The framework is a simple, unconventional care model that prioritizes listening to, and then organizing learnings from, the individuals we serve to determine the best approach to care.

“For our pilot market in Ascension St. Joseph Hospital in Milwaukee, our team spent time getting into the community — meeting patients where they are, including at the Special Supplemental Nutrition Program for Women, Infants, and Children department; food pantries; community baby showers; churches; and more,” Allison said. “By engaging with our patients, we learned directly from them what was preventing them from getting to their appointments, such as lack of child care and transportation.”

The team also learned that communication between the patient and the care team is essential. Maternal health navigators and social workers are embedded into the initiative to better support patients throughout their pregnancy while also providing a warm handoff to clinical teams.

Nubia Rojas, MSW, Maternal Health Navigator, and Sharthedria “Shar” Crawford, Patient Navigator, are two associates who serve at Ascension St. Joseph Hospital.

“As navigators, we work one on one with our maternal health patients to coordinate their appointments with their OB-GYN along with any other providers they may see across Ascension,” Shar said. “We are also here to listen to our patients, understand what they may need, and connect them to any resources from Ascension or the local community to better support their health.”

BUILDING STRONG PATIENT RELATIONSHIPS

When she was 10 weeks pregnant, patient Crystal enrolled in the initiative with her third child. Not only was she expecting, she was also managing multiple health conditions including pulmonary valve stenosis, fibromyalgia, a history of pelvic inflammatory disease and pregnancy-induced anemia. Throughout Crystal’s pregnancy, the navigator team worked to coordinate not only her prenatal appointments but also her appointments with her cardiologist and primary care doctor so all members of her care team had a full picture of her health.

“I call Ascension St. Joseph my family,” Crystal said. “I did not have a car, but I did not miss one appointment. Shar and Nubia were able to set me up with [a ride service] whenever

From left, patient Crystal; Sharthedria ‘Shar’ Crawford, Patient Navigator, holding baby Loyal; and Nubia Rojas, MSW, Maternal Health Navigator, at Ascension SE Wisconsin Hospital – St. Joseph Campus in Milwaukee.

I needed it to help get me to and from St. Joseph’s. I talk to them almost daily even three months after my son’s delivery. I have never felt more comfortable with my doctors and truly trust Ascension with my care.”

The team’s work did not stop once Crystal delivered. Shar and Nubia helped support her through postpartum depression and connected her with Ascension’s lactation consultants as well as resources for diapers, formula, clothing and food to keep her and her baby son healthy.

“We are so proud of Crystal,” Nubia said. “Our goal with the initiative is not only to get expecting moms to their prenatal appointments, but to empower our patients. Crystal is now a strong advocate for her health and is a testament to why we champion this work.”

INCREASING ACCESS TO CARE

To further support the navigation team’s efforts, the Ascension Medical Group OB-GYN clinic at Ascension St. Joseph also offers a child waiting area where nursing students watch children of expectant and new mothers while they get the care they need.

“In the past 12 months, the child waiting area at Ascension St. Joseph’s has enabled more than 130 appointments, which would have been missed without the service,” said Mary Paul, Vice President, Solidarity and Social Accountability, Ascension. “The child waiting area has also recently seen an increased use for the children of pregnant women who are receiving IV iron infusion and IV hydration, with more than 216 encounters. It is believed that these women would have either sought care in the emergency room or not received the IV hydration at all.”

In addition to the Wisconsin market, the Maternal Health Social Systems Initiative has launched in Florida and Michigan and will soon be live in Kansas. These other markets are seeing similar success in reducing appointment no-shows by using their own unique strategies to match the needs of their communities.

“For example, when we launched the program in Florida, we learned that mass transportation in the area was lacking,” Allison said. “Many of our patients had no means to get to their prenatal appointments. With a ride-share partnership now in place, more than 537 patients have been able to use the service to make it to their prenatal/postpartum visits at no cost to them.”

SHAPING OUR COMMUNITIES FOR A BETTER TOMORROW Beyond the Maternal Health Social Systems Initiative, Community Health Needs Assessments will also soon play a role in shaping the health of our communities. In the coming year,

A nursing student at Ascension SE Wisconsin Hospital – St. Joseph Campus tends to a child waiting area where students watch children of expectant and new mothers during their medical appointments.

Ascension will be working to define a set of health equity measures to identify the widest disparities each market faces. This data will allow for more targeted strategies to drive and support improvement efforts.

Today, clinicians and associates can also help address social determinants of health through an online platform called Neighborhood Resource. Neighborhood Resource is a free and easy-to-use tool that connects those in need to social services and resources right in their own community. Through a simple ZIP code search, patients can find free or reduced-cost services in their community, including food, housing, transportation, job training, legal help and more.

Team members from the Ascension Sacred Heart Women’s Center in Pensacola, Florida, used both the Neighborhood Resource platform and the SDoH screening tool to help them understand potential barriers to maternal care. They learned that lack of transportation is a major contributor to a large number of no-show appointments. Those patients without transportation were identified and connected to a ride-share service to help them get to prenatal and postpartum appointments. Additionally, food insecurity was identified as a critical social determinant of health for their patients. To overcome this barrier, the Ascension Sacred Heart Population Health team formed a food pantry to provide healthy staple items.

“We look forward to continued collaboration across our clinical enterprise to better serve our underserved populations,” Dr. Garrett-Ray said. “By working together, we can deliver more equitable care for the communities we serve.”

“By engaging with our patients, we learned directly from them what was preventing them from getting to their appointments, such as lack of child care and transportation.”

— ALLISON MCNEIL, MSN, CNM, SENIOR DIRECTOR - COMMUNITY IMPACT, ASCENSION ASCENSION MEDICAL GROUP SCREENING TOOL HELPS ADDRESS SOCIAL NEEDS

Ascension’s commitment to being a national leader in the advancement of health equity is one of the most authentic expressions of our Mission, Vision and Values. Identifying social determinants of health (SDoH) is one important way to reduce preventable disparities in health outcomes.

This past June, Ascension Medical Group’s (AMG) standardized screening tool to help Ascension address social needs reached a major milestone — the 1 millionth screening.

“Advancing health equity begins by listening and understanding the needs of the populations we serve, especially those who are poor and vulnerable,” said Baligh Yehia, MD, MPP, FACP, Senior Vice President, Ascension, and President, Ascension Medical Group. “One million screenings is an incredible testament to our clinicians’ and associates’ commitment to providing equitable care.”

In January 2020, the standard screening tool was deployed at several AMG primary care clinics. The tool’s questions cover topics such as loneliness, violence, food insecurity, housing, education and financial issues — all things that can influence a patient’s overall health and well-being. Today, the tool is being used across all AMG primary care and some specialty offices including pediatrics and obstetrics practices.

Thanks to AMG’s collective efforts from its clinicians, associates and collaborators including the Ascension Data Science Institute, AMG is now conducting more than 85,000 SDoH assessments each month with its patients.

This work also supports the Ascension Strategic Plan’s emphasis on integrating Mission through community impact, particularly focusing on individuals who are poor or vulnerable. As Ascension looks to the future, we plan to expand the SDoH screening tool across all points of care including acute and post-acute care.