CA legislation,



Strategies and Resources to eliminate Racism in WA Perinatal Healthcare SystemsRacism affects medical decisions and quality of care, and contributes to persistent perinatal health disparities based on race/ethnicity. This tool is designed for use by healthcare clinicians, administration, academic medicine faculty and other allied perinatal health professionals. While many resources are specific to perinatal healthcare in WA state, they could be adapted for use in other healthcare settings. While racism is uniquely experienced by all non-white races and ethnicities, many of these resources and strategies center Black and American Indian/Alaska Native (AI/AN) communities, since they are most impacted by perinatal healthcare disparities. There is increasing evidence that Pacific Islanders (PI) are disproportionately represented as well, and resulting action from this tool should include representation from this population. This document is not intended to be an inclusive list, but offers an approach to targeting the issue from multiple angles, each reflected in the categories included. Racism must be addressed and eliminated through the coordinated efforts of every person involved across multiple categories within healthcare systems. This document is searchable, and provides imbedded links within categories.Strategies and resources are organized under the following ten categories:1. Academic Medicine 2. Diversification of Workforce3. Policy and Legislation4. Improving Care for All5. Research6. Stories7. Community-Led Care Models8. Patient/Provider Relationship9. Individual Change10. Healthcare Systems ChangeAcademic medicine (AM)Since the scope of AM is wide, there are many opportunities within its system to address racism. Alongside educating the next generation of healthcare professionals and supporting faculty and administration, AM provides medical care to a large percentage of the US population. AM engages in research and sets the precedent for the direction of the healthcare professions. Therefore, AM should be a leader towards diversification of the healthcare workforce. Strategies should be implemented and strengthened at each step towards graduating more underrepresented students of color into the medical field. In addition, more AM faculty and administration from underrepresented races and ethnicities should be recruited and and promoted. Curriculum should be culturally-relevant and train a workforce that can provide optimal healthcare for all communities. Community partnerships increase interest in careers in medical fields and create avenues for accessing academic institutions by building relationships. Some examples of partnerships include Kaiser Permanente Medical Days at community clinics and healthcare career education in public school curriculum. When youth or adults who are thinking about enrolling in higher education have the opportunity to learn about becoming healthcare professionals from people they witness succeeding in the medical field, especially when they look like them, they are more likely to want to pursue it themselves. Representation matters. Increase funding options, including free tuition options, for underrepresented medical students of color, especially those starting their education at community colleges and regional universities. A recent study showed that more diverse students are enrolled at Associate’s colleges, but they receive significantly less funding than other colleges and universities, and therefore, graduate fewer students. Recommendations for state-level actions are included. The Health Profession Opportunity Grants (HPOG), administered by the Administration for Children and Families, U.S. Department of Health & Human Services, was created as part of the Affordable Care Act to provide education and training to Temporary Assistance for Needy Families (TANF) recipients and other low-income individuals, as well as Tribal entities, for healthcare occupations that pay well and are in high demand.? Harvard Medical School believes that the education of a physician is enhanced by the diversity of the student body. HMS currently has 157 underrepresented students enrolled for the 2019 school year- 69 African Americans/Blacks, 35 Mexican Americans, 12 Puerto Ricans, 34 Other Hispanics, and 7 Native Americans- representing 22 percent of the student body. Since 1969, HMS has graduated more than 1,350 underrepresented physicians. The Office of Recruitment and Multicultural Affairs (ORMA) has comprehensively operationalized this commitment through admissions, recruitment, student services and funding options.“Rooting out implicit bias in admissions” Association of American Medical Colleges (AAMC) article about addressing implicit bias on admissions committees, and the results of OSUCOM study that it references.Faculty Diversity Resources at University of WA’s Center for Equity, Diversity and Inclusion (CEDI). Includes Search Committee resources, and Implicit Bias trainings, and fellowship information. Integrate Structural Competency (SC) content into all curriculum. SC is a new approach to the relationships among race, class, and symptom expression. It bridges research on social determinants of health (SDH) to clinical interventions, and prepares clinical trainees to act on systemic causes of health inequalities. Clinical care has long been focused on the individual, and often restricts the scope of cultural competency training to the beliefs and behaviors of individual patients.?SC aims to develop a language and set of interventions to reduce health inequalities at the level of neighborhoods, institutions and policies. Articles about Structural Competency.Integrate Implicit Bias awareness training into all curriculum. See other Implicit Bias resources listed under Diversification of Workforce and Individual Change categories. Gonzalez, Cristina & Y Kim, Mimi & Marantz, Paul. (2014). “Implicit Bias and Its Relation to Health Disparities: A Teaching Program and Survey of Medical Students.” Teaching and learning in medicine. Vol 26. 64-71. This article describes an educational intervention addressing both health disparities and physician implicit bias, and reports the results of a subsequent survey exploring medical students’ attitudes and beliefs toward subconscious bias and health disparities. The authors recommend making this instruction part of the compulsory, longitudinal undergraduate medical curriculum. Prioritize methods of learning on multidisciplinary teams as best practice. See Diversification of Workforce for other resources on interprofessional collaboration. Gergerich, Erika, et al. (2018). “Hierarchies in Interprofessional Training.”?Journal of Interprofessional Care, pp. 1–8.Adverse patient outcomes are often the result of conflict or poor communication among healthcare professionals. Use of interprofessional care teams can improve healthcare and delivery of services. Healthcare systems have been historically hierarchical in nature with physicians regularly taking a leadership position which can be a source of conflict. This article analyzes qualitative data from a four-day interprofessional training for family medicine residents, pharmacy students, nurse practitioner students, and psychology students.?“Students simulate real-life maternal death story”: An article about a interprofessional team simulation at Caldwell University.Other Academic Medicine resources and articles:Established in 2015, Social Medicine Consortium (SMC) is a collective of committed individuals, universities and organizations fighting for health equity through education, training, service and advocacy, with social medicine at its core.?SMC recognizes that health professionals are regularly exposed to socioeconomic forces that prevent optimal health for their patients, but have extremely limited knowledge of and experience with how to effectively respond, due in large part to an absence of routine training on the social determinants of health in health profession training and continuing education.?Read and sign onto the SMC’s Consensus StatementBetancourt, Joseph R. (2006). “Eliminating Racial and Ethnic Disparities in Health Care: What Is the Role of Academic Medicine?”?Academic Medicine: Journal of the Association of American Medical Colleges, vol. 81, no. 9, pp. 788–792.This article highlights and operationalizes the recommendations made by the Institute of Medicine (IOM) Report Unequal Treatment, released in 2002. The IOM report, available free online, remains the “preeminent study of the issue of racial and ethnic disparities in healthcare in the US.” Betancourt’s article provides general and specific recommendations to address racial and ethnic disparities in healthcare, focusing on a broad set of stakeholders, including academic medicine. Murray-García, Jann L., et al. (2014). “Dialogue as Skill: Training a Health Professions Workforce That Can Talk About Race and Racism.”?American Journal of Orthopsychiatry, vol. 84, no. 5, pp. 590–596.This article establishes the need for the skill of dialoguing explicitly with patients, colleagues, and others about race and racism. Health professions educators and institutional leaders can play a pivotal role in reducing racial disparities in healthcare encounters by actively promoting, nurturing, and participating in this dialogue, and modeling its value as an indispensable skill and institutional priority.Diversification of Workforce Academic Medicine strategies continue into all other healthcare settings since the flow of more underrepresented students of color into healthcare systems will diversify the workforce. Additional strategies provided in this category will support a more diverse workforce and ensure a comprehensive shift towards more culturally relevant care for everyone. All providers and administration will have opportunities to improve care and policies for communities most impacted by perinatal disparities, build better working relationships within a diverse workforce, and possess the drive to become more culturally versatile and aware of their own biases. Resources that aid in the diversification of the healthcare workforce can also be found in Academic Medicine, Policy and Legislation, Healthcare System Change, and Patient/Provider Relationship categories. Smedley, Brian D., et al.?(2004). In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. National Academies Press.Despite the rapid growth of racial and ethnic minority groups in the US, their representation in health professions has grown only modestly in the past 25 years, prompting the creation of initiatives to increase diversity in health professions. This Institutes of Medicine (IOM) report, available free online, considers the benefits of greater racial and ethnic diversity, and identifies institutional and policy-level mechanisms to garner broad support among health professions leaders, community members, and other key stakeholders to implement these strategies. Recruit, hire and promote more healthcare providers and healthcare administrators from underrepresented races and ethnicities. “A Toolkit for Recruiting and Hiring a More Diverse Workforce” PDF created by University Health Services at the U of CA at Berkeley. “Racism still a problem in healthcare's C-suite: Efforts aimed at boosting diversity in healthcare leadership fail to make progress” 2018 article from Modern Healthcare.Provide continuing education opportunities about structural competency and implicit bias for all healthcare professionals and administration, ensuring that skills are practiced in small group settings and on interprofessional teams. Practice of these skills is unique from other standardized medical skills since they will never result in mastery, and therefore, should be presented and practiced in different ways. With a more diverse workforce, more healthcare professionals will possess the drive to engage in building these skills interpersonally with both patients and colleagues. Relationship building is key to changing the culture of healthcare systems and providing better care for all patients. What Is Bias, and What Can Medical Professionals Do to Address It? IHI: Institute for Healthcare Improvement: Short video introducing the concept of bias. Byrne, A., & Tanesini, A. (2015). “Instilling New Habits: Addressing Implicit Bias in Healthcare Professionals.”?Advances in Health Sciences Education, vol. 20, no. 5, pp. 1255–1262.Link to article. “A key concept…is not to see clinician/patient interaction as a simple exchange of information but rather as equivalent to the complex and fast moving interactions of a high level sport or dance…without expertise developed through years of practice, performance will inevitably be poor. This leads to a clear distinction between education as the acquisition of specific knowledge and skills, and education as personal transformation through experience, practice and personal commitment to change.”Nelson, Stephen. (2016). “Race, Racism, and Health Disparities: What Can I Do About It?”?Creative Nursing, vol. 22, no. 3, pp. 161–165. This article provides details and links to study results about a training module “to help healthcare providers address individual racial bias, the role of racism in evidence-based medical protocols, and the realities of systemic racism and its impact on patients. Hardeman, R., Medina, E., & Kozhimannil, K. (2016). “Dismantling Structural Racism, Supporting Black Lives and Achieving Health Equity: Our Role.”?The New England Journal of Medicine,?375(22), 2113-2115.This NEJM article makes recommendations for how to address structural racism within healthcare systems that include naming and recognizing racism- not just race, understanding how racism has affected the narrative about disparities, and “centering at the margins” (bell hooks), when creating programs and policies. Prioritize collaboration on interprofessional (or multidisciplinary) teams as best practice. Vanderbilt AA, et al. (2015). “Reducing Health Disparities in Underserved Communities via Interprofessional Collaboration across Health Care Professions.”?Journal of Multidisciplinary Healthcare, vol. 8, no. default, pp. 205–208.Link to article. Interprofessional collaboration assists in reducing health disparities because it brings a comprehensive team (e.g. physicians, pharmacists, nurses, social workers, researchers) to treat the patient in addition to providing the community as a whole with experts.?Institutions should provide the infrastructure necessary to support interprofessional healthcare teams since it has the potential to save money, provide better health outcomes for patients, and streamline the healthcare process.?Policy and legislationIntroduce and support policies and enforce legislation that address racism in healthcare systems. Provide funding and infrastructural support for evidence-based interventions known to improve outcomes for those most affected by persistent disparities in perinatal healthcare. Federal and state laws and systems exist at the structural level, and therefore support change at all other levels. Create policies and legislation using Targeted Universalism. In this framework, universal goals are established for all groups concerned. The strategies developed to achieve those goals are targeted, based upon how different groups are situated within structures, culture, and across geographies to obtain the universal goal.Short Video (4 min) about Targeted Universalism featuring john a. powell, director of the UC Berkeley Haas Institute for a Fair and Inclusive SocietyKindig, D. (2017). Population Health Equity: Rate and Burden, Race and Class.?JAMA,?317(5), 467-468. Article discusses why a targeted, or proportionate, universal policy approach is necessary. “The effort to reduce health disparities is hindered by viewing health equity only in terms of racial inequities.” Video of House Ways and Means Committee hearing “Overcoming Racial Disparities and Social Determinants in the Maternal Mortality Crisis” May 16, 2019 including testimony from Allyson Felix, track and field star athlete, Dr. Patrice Harris, the current President of the American Medical Association (AMA), and Dr. Loren Robinson, Deputy Secretary for Health Promotion and Disease Prevention, Pennsylvania Department of Health. "How 2020 Democrats would tackle the problem of startlingly high rates of maternal deaths in the US" Article details each candidate plans’ to address the issue, and links to current bills. “State Legislators Are Finally Doing Something About the Black Maternal Health Crisis” State lawmakers have introduced more than 80 bills this session to address the disparity in Black maternal and infant mortality rates.Numerous efforts exist across the US to achieve the goal of Medicaid coverage for doula care. This National Health Law Program resource tracks info on the latest state and federal bills supporting doula care for low-income people. Policy Brief detailing WA’s efforts to achieve the goal of Medicaid coverage for doula care. A workgroup, Doulas for All Washington State, currently exists comprised of stakeholders from multiple communities who are working on getting the legislation into practice. The goal of the Black Maternal Health Caucus is to "raise awareness within Congress to establish Black maternal health as a national priority, and explore and advocate for effective, evidence-based, culturally-competent policies and best practices for health outcomes for Black mothers," according to a statement released by the offices of Rep. Underwood and Rep. Adams.ACOG supports passing a MOMNIBUS. Three bills that together comprehensively authorize the AIM programs, extend Medicaid coverage for a year after birth, address implicit bias and cultural competency in healthcare systems, and support state-based perinatal quality collaboratives. HYPERLINK "" H.R. 1551 Quality Care for Moms and Babies Act HYPERLINK "" H.R. 1897 MOMMA’s ActS. 116 MOMS ActH.R. 2602, Healthy MOMMIES Act, introduced by Congresswoman Ayanna Pressley, expands care options for low-income pregnant and postpartum individuals to include more community-based options including free-standing birthing centers and doula support, and provides funding to study telemedicine options for perinatal care. Senator Kamala Harris introduced S. 1600, Maternal Care Access and Reducing Emergencies (CARE) Act which provides funding for implicit bias training for health professionals, and funds community-based care models targeting vulnerable perinatal populations. Introduced by Rep. Gwen Moore, H.R. 2751, Mamas First Act, requires state Medicaid programs to cover doula and midwife services, including prenatal, delivery, and postpartum services.CA legislation, SB-464 California Dignity in Pregnancy and Childbirth Act, requires CA perinatal healthcare providers to complete ongoing implicit bias training.S. 1037 The Rural Health Clinic Modernization Act of 2019, introduced by Sens. John Barrasso (R-WY) and Tina Smith (D-MN), aims to expand the services offered by rural health clinics to improve access to care and close coverage gaps in underserved areas of the country.Improving care for allHealth Equity is defined by Dr. Camara Jones, a well-known family physician and epidemiologist whose work focuses on the impacts of racism on the health and well-being of the nation, as “the assurance of conditions for optimal health for all people”. Understanding how each person benefits when all people in a community are experiencing optimal health is a critical perspective that assists in developing equitable relationships in racial equity work that are built on mutual respect and shared goals, not charity or power. “If you have come here to help me you are wasting your time, but if you have come because your liberation is bound up with mine, then let us work together.” Lilla Watson- Indigenous activist, academic and artistWoolf, S., & Aron, L. (2013). The US Health Disadvantage Relative to Other High-Income Countries: Findings from a National Research Council/Institute of Medicine Report.?JAMA,309(8), 1-2.The US spends more on healthcare than any other country, but its health outcomes are generally worse than those of other wealthy nations. This article, available through JAMA membership, reports that the US health disadvantage is more pronounced among vulnerable populations, but it also can be found among more privileged groups. Even non-Hispanic white adults or those with health insurance, a college education, high incomes, or healthy behaviors appear to be in worse health in the US than in other high-income countries.Targeted Universalism is an approach to policy creation that targets strategies towards specific groups while ensuring that all groups meet universal goals. Bringing US Black, AI/AN and Pacific Islander mortality and morbidity rates for childbearing people up to the levels of other races/ethnicities is not enough, since more privileged groups are not in optimal health either. Ensuring that all communities’ perinatal health outcomes improve, while targeting interventions towards those most affected, will result in more collaboration from all communities. Dr. Camara Jones' April 2017 talk "Tools for a National Campaign Against Racism," held at the Social Medicine Consortium Conference in Chicago, IL. An engaging presentation on health equity that defines how “racism saps the strength of the whole society through the waste of human resources.” Why Lead with Race? Government Alliance on Race and Equity (GARE).Leading health equity work with a lens focused on race is important because “one size fits all” strategies often leave out marginalized communities. Interview with AMA’s first ever Chief Health Equity Officer, Aletha Maybank, and the AMA’s Health Equity Policy Statement. “I see an opportunity for the AMA to move even more upstream—to expand the use of our power and platform to advocate more directly for the conditions that we know support living healthier lives, such as food security, housing affordability, stability and quality, transportation equity, and economic justice.”Research Research plays an important role in the creation of policies and interventions that will improve care for those most affected by racism in perinatal healthcare. Funding should invest in studies that affirm and improve interventions and community-based models for care that are known to work. Research should not be singularly focused on showing perinatal health disparities for communities most impacted without also funding interventions to eliminate them. In general, there is an absence of AI/AN and Pacific Islander (PI) focused and led research regarding perinatal health and healthcare. In addition, more study should gather strengths-based data about what is working for Black, AI/AN and PI childbearing people who have excellent outcomes. The presentation of qualitative data using unique methods such as theatrical readings and community events can help important findings reach more communities not connected to academic research. Accurate data collection of the race and ethnicity of perinatal healthcare patients is crucial towards understanding how policies, interventions and models of care are impacting persistent disparities in perinatal healthcare outcomes. For every death, at least 60 patients experience a severe morbidity; better tracking of these “near-misses” would provide more data to learn from. Battling over Birth: Black Women and the Maternal Health Care Crisis Black Women Birthing Justice (BWBJ) 2018 report of a participatory research project that collected stories from 100 black women who birthed in CA; includes key findings and recommendations. “Decolonizing Data and Research in Black Maternal Health” Presented by Black Mamas Matter Alliance (BMMA) Webinar featuring “Future Implications: Designing Research using a Reproductive Justice Lens” by Dr. Monica McLemore. (at 1:10 min) “Who Counts? Racial Misclassification and American Indians/Alaska Natives” Presented by Urban Indian Health Institute (UIHI) This webinar discusses how racial misclassification and limited analysis have excluded AI/AN populations from health assessments and community conversations, and provides training to improve capturing the race of AI/AN people in data.“American Indian and Alaska Native Maternal and Infant Mortality: Challenges and Opportunities” Center for American Progress Report “Although there is little research or media attention on American Indian and Alaska Native maternal and infant health, evidence suggests parallels to African American women’s experiences.” “What blame-the-mother stories get wrong about birth outcomes among black moms” by Dr. Monica McLemore, whose recent research has focused on new methods such as having women generate, rank, and prioritize the research questions that matter most to them — this has allowed funders and researchers to hear from women at high social and medical risk for preterm birth to determine what their priorities for care are.Stories Listening to and learning from the lived experiences of the people and communities most impacted by persistent perinatal disparities is paramount towards developing culturally relevant programs and policies, and building relationships with patients based on mutual goals for healthcare. Battling over Birth: Black Women and the Maternal Health Care Crisis Black Women Birthing Justice (BWBJ) 2018 report of a participatory research project that collected stories from 100 black women who birthed in CA; includes key findings and recommendations. “Death by Delivery” The Naked Truth, a documentary TV series. This episode addresses structural racism and its impact on morality for black childbearing people. “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis: The answer to the disparity in death rates has everything to do with the lived experience of being a black woman in America.” New York Times Magazine article from 2018. “Black Mothers Respond to Our Cover Story on Maternal Mortality” New York Times Magazine asked readers to share their stories of struggling to receive proper prenatal and postnatal care, and hundreds of people responded.?Follow up article to previous link. “Obstetric Racism: The Racial Politics of Pregnancy, Labor, and Birthing” by Dána-Ain Davis- This article describes how black women’s stories of perinatal healthcare encounters in the US illustrate Obstetric Racism. “The context in which women interpret those experiences is the result of being knowledgeable subjects who have lived their lives in a country where the legacies of racism, evidenced by the racial capitalism of enslavement, segregation, and medical experimentation, influence their understanding of the treatment they receive.”"Canadian Indigenous Women’s Perspectives of Maternal Health and Health Care Services: A Systematic Review" Availability of healthcare resources, consideration of socio-economic or lifestyle barriers to health, and the impact of colonization on interactions with healthcare providers were main factors that impacted Indigenous people’s perinatal health experiences. Medical evacuation was often due to limited maternity care options available in remote communities, and was associated with emotional, physical, and financial stress. “Mothers Matter: Washington moms at unacceptable risk during childbirth” KING-5 story about a family’s positive experience as they were supported by their Outreach Doula, Rokea Jones, from Open Arms Perinatal Services. "Notes from a Congressional Briefing on Native American Maternal Health" 2019 article. Indigenous leaders shared stories and their perspectives on the policy changes that are needed to improve perinatal health and related reproductive rights issues in their communities.“The Secret to Black Women’s Health: Ask, Listen, Do” by Linda Goler Blount. “Black Women’s Health Imperative (BWHI) collected responses from 3,800 Black women on how they defined health. The results of the survey, IndexUS: What Healthy Black Women Can Teach Us About Health suggest that the way public health professionals have gone about developing and implementing programs to address Black women’s health for the past thirty years has been largely wrong.” Since the actual survey is currently unavailable, this article provides key findings and discussion. National Birth Quality Collaborative (NBEC) is partnering with ACOG and CMQCC to develop and apply a community-informed theoretical model in the creation and testing of a participatory patient-reported experience metric (PREM) of mistreatment and discrimination in childbirth. This project, “Mother’s Voices Driving Birth Equity”, funded by the Robert Wood Johnson Foundation, will create opportunities for Black mothers’ stories to be valued, seen, and heard in semi-structured focus group munity-led care modelsCommunity-models of care should be created and led by those most impacted by the issues they address, whenever possible. Community-led and community-based are not the same. Providers and healthcare systems should support, work as allies in partnership with, and provide referrals to local community-led care options for those most impacted by persistent disparities in perinatal healthcare. Connecting patients to community-led models of care promotes consumer empowerment and education. In addition, there are other evidence-based models of care that could be specifically targeted towards these communities listed below. Many resources are specific to the Puget Sound region, and those utilizing this resource should become familiar with resources similar to those listed in their own area of practice. Black Women’s Health Imperative (BWHI) The first nonprofit organization created by Black women in 1983 to help protect and advance the health and wellness of Black women and girls in the US. Through investments in evidence-based strategies, BWHI delivers bold programs, and advocates for health-promoting policies, consumer awareness and involvement.United Indians of All Tribes Foundation provides educational, cultural and social services that reconnect Indigenous people in the Puget Sound region to their heritage by strengthening their sense of belonging and significance as Native people. Daybreak Star Doulas, currently in creation, will be an indigenous model of full-spectrum doula and breastfeeding support services for urban Indian women and their families through the childbearing year. View the Job description for doula positions. Open Arms Perinatal Services, founded in 1997, serves?over 300 low-income pregnant people and their infants in King County each year through its programs. Community-Based Outreach Doulas provide services to birthing people and their families in their own community during pregnancy and early parenting. They pair Somali, Latinx, African American, and American Indian Alaska Native clients with doulas who are culturally and/or linguistically matched, whenever possible. Doulas, starting in the second trimester until two years after birth, provide support through case management, home visits, labor/breastfeeding support, and parent bonding/education. 2019 Overview of Programs and 2017 Outcomes for the Outreach Program.Families of Color Seattle (FOCS) is a non-profit organization that is connecting parents to build a loving community of families of color. Founded in 2013, FOCS is led by mothers of color. Their programs include parent groups, community resources and events, and racial equity consulting. FOCS supports a vibrant community on their Facebook page, as well. Rainier Valley Community Clinic?provides high quality, individualized perinatal care and family medicine to women and families in the South Seattle area to improve health outcomes for traditionally underserved communities.?They are dedicated to increasing capacity within the community for jobs in the healthcare industry for local women, especially those of color and immigrant women. They offer a CenteringPregnancy group for its patients. HealthConnect One, founded in 1988, is the national leader in advancing respectful, community-based, peer-to-peer support for pregnancy, birth, breastfeeding and early parenting. Through training and consulting, they co-create programs specific to each community, build leadership from the ground up, and amplify and support community leaders who are working for birth equity. Open Arms Perinatal Services is a local community-based program that is nationally-accredited with HealthConnect One. Tackling Maternal Health Disparities: A Look at Four Local Organizations with Innovative Approaches?An excellent article that profiles Commonsense Childbirth, Mamatoto Village, Breath of my Heart Birthplace, and Mama Sana Vibrant Woman- all community-based models working towards becoming community-led by developing leadership from the communities they serve. It compares outcomes and funding structures for each, and offers policy recommendations to support their efforts. Mewinzha Ondaadiziike Wiigaming, a Native American Indian organization in Minnesota, is committed to community-centered holistic care for all pregnant and birthing parents and their families through doula care, education and home visits. The following are other national or Puget-sound based models of care, and/or funding opportunities for models of care, aimed to support all childbearing people, but are not community-led. Some offer special programs that target or could be targeted specifically towards communities most impacted by perinatal health disparities:CenteringPregnancy is a group prenatal care models that brings 8-10 pregnant people due at the same time out of exam rooms and into a group?setting. Published studies show that Centering parents attend more prenatal visits, and Centering nearly eliminates racial disparities in preterm?birth. UCSF offers CenteringPregnancy for Black Women. Article in Mother Jones, “A Surprisingly Simple Way Black Women Can Reduce Pregnancy Risks”Swedish Medical Center, in the Puget Sound region, offers birth and postpartum doulas for its patients through their Doula Program, and is dedicated to the diversification of the local doula community through their Doula Diversity Scholarship. In 2017, the program began offering free birth doula services to low-income families in addition to paying families, and has served over 300 low-income families since. View their 2018 Program Report.Since 1983, the Program for Early Parent Support (PEPS), a 501(C)(3) nonprofit organization in the Puget Sound region, has helped parents connect and grow as they begin their journey into parenthood. PEPS parent support programs educate, inform and create community using the evidenced-based Strengthening Families framework.Nurse Family Partnership- The NFP model, along with the trusted relationship between a nurse and mother, creates protective factors for parents and their babies against the societal challenges that contribute to toxic stress, systemic racism, and adverse pregnancy outcomes.?Read NFP’s Statement on the Maternal Mortality Crisis.The Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) funds states, territories, and tribal entities to develop and implement evidence-based, voluntary programs that best meet the needs of their communities. The goals of the program include improving health of childbearing people and their families through regular, planned home visits from health, social service, and child development professionals. The Tribal Home Visiting program is funded by a 3 percent set-aside from the larger MIECHV program. Grants are awarded to Indian tribes, consortia of tribes, tribal organizations, and urban Indian organizations. Watch a short video about successes of the program, and see examples of tribal programs across the US at this link. In addition, access to healthcare for rural communities is often poor. Tailoring programs towards those living rurally who are most affected by persistent disparities in perinatal healthcare outcomes should be an area of focus, especially since many rural areas are home to AI/AN communities. Here is an example of a residency program in WI focused on OBGYN care for rural communities. The Seattle Indian Health Board also offers a Family Medicine Residency Program focused on the needs of the AI/AN community, including those living rurally. Patient/Provider relationshipThe relationship between a patient and their healthcare team is a critical place where trust is built and collaboration leads to better health. The demands of busy schedules and the lack of continuity of care for people experiencing pregnancy works against the best intentions of a clinician. There are currently a wealth of media sources reporting about poor US mortality and morbidity rates for childbearing people, especially Black people. While it is important for the public to understand this issue and for providers to acknowledge it during visits, if opportunities for action are not provided alongside information, a patient can be left feeling excess fear. Empower patients and their communities by offering resources as well as building a strong relationship. Recognize options for healthcare that exist outside your healthcare system, including a patient’s community as partners. Providers should learn who the members of a person’s community are, and express that they are important and welcomed during most medical care. Providers and staff should offer culturally relevant education and skill-building for a patient’s support team, and if present, involve them in appropriate areas of care including prenatal care visits, labor support and postpartum follow-up care. “Time to Start Using Evidence-Based Approaches to Patient Engagement” NEJM Catalyst article. “Would you trust a surgeon who told you, “I haven’t had any formal training for this procedure, observed any experts, nor received feedback on my skills, BUT over the course of time, through trial and error, I think I’ve found what works for me”? That is essentially how physicians were “trained” in communication skills for decades. While communication skills training is not a healthcare panacea, it can reliably improve quality of care, patient outcomes, and patient and provider experience.” Transition between provider shifts “at the bedside” and involve patients, when possible. When the RN, CNM or MD shift changes, provide a patient and their support team the opportunity to witness the transition of care and ask questions. As the outgoing clinician, provide context not reflected in the chart notes that assures a family that their needs and goals will continue to be recognized by the new shift. For example, “Throughout our time together it has been important for Mari to have the lights dim during exams since she gets migraines with bright direct lighting, so I’ve been using the spotlight instead of turning on the overheads, and her partner has been great at assisting me. Is there anything else you’d like to make sure your new RN is aware of before I go?” As the incoming clinician, take a few minutes to witness how the outgoing provider interacted as a member of the team before rushing in. It is likely that the family is feeling unsure of the transition, and your inclusion as a fresh member of the team will be more positive if you adjust to their pace, much like in a relay race. Bittle, M., Forward, C., & Power, M. (2015). Best Practices for Transitioning from the Birthing Unit to the Mother–Infant Unit.?Journal of Obstetric, Gynecologic, & Neonatal Nursing,?44(S1), S27.This article discusses an evidence‐based project that transitions the mother/infant dyad from the birthing unit to the postpartum room for admission care while integrating face‐to‐face interprofessional bedside hand‐off. The traditional practice of telephone hand‐off is time consuming, inefficient for nurses with multiple demands, does not engage the patient and family, and is not conducive to a seamless transition from one unit to another.Implement the use of Whiteboards in perinatal hospital systems. HYPERLINK "" “Overlake and Evergreen launch pilot to improve mothers’ childbirth safety and experience: Quality improvement program aims to reduce C-sections and increase adherence to birth plans”This simple tool, increasingly common in perinatal hospital rooms, aides the flow of communication between shifts, and improves continuity of care, patient safety and satisfaction rates. Examine your healthcare system’s written policies and unwritten practices regarding visitors. Ensure they are unbiased, equally enforced, and focused on the inclusion of community members, if a patient so desires. Create a culture that welcomes family and community members as team members towards improving healthcare outcomes for all childbearing people. Patient/Provider relationship building skills Developed by leading health literacy experts,?"Ask Me 3" promotes three simple but essential questions that patients should ask their providers in every healthcare interaction.“Teach-back” is an important step towards shared-decision making, and a strategy to validate that information has been explained clearly and that patients and family members clearly understand what they have been told. Practice this skill using an interactive module and webinar. HYPERLINK "" Liberation in the Exam Room: Racial Justice and Equity in Health Care “Liberation is about working together in new ways that are self-reflective and rooted in history to address structural racism in health care — and to go beyond providing services, to our own personal roles as health care team members in dismantling oppression.” This toolkit, developed by Southern Jamaica Plain Health Center?in Massachusetts, provides concrete steps that all healthcare providers can implement “in the exam room”. Here are just a few:Set up visual cues. Create a safe and welcoming environment for your patients and their support team that celebrates and acknowledges their identity and culture. Ex. Black Lives Matter poster, posters in the preferred language of patients, or a poster stating that people of all documentation statuses/races/gender identities/religions are welcome. Ask Better Questions About identity: “I don’t want to assume anything about your identities. How do you identify racially, ethnically, culturally?” About experiences in the healthcare system: “Many of my patients experience racism in their healthcare. Are there any experiences you would like to share with me?” About life experiences: “Are there important life events that you’ve experienced that has or is currently affecting your health?” Ask relevant follow up questions to the patient. To the best of your ability, make sure they feel heard and that you address their concerns or past negative experiences, and incorporate what they share into your care plan. Individual ChangeEvery person has bias. Becoming aware of how it manifests in our personal life and work is important. Individual efforts to become aware of racism and privilege, and implicit bias are on-going, and there are many options for engagement. The following are examples of podcasts, books, interactive screening tools, articles and videos designed to evoke individual reflection and drive actions to address individual racial bias, not only in healthcare, but in everyday life. Take the Implicit-Association Test (IAT) at Harvard’s Project Implicit. Project Implicit is a non-profit organization and international collaborative network of researchers investigating implicit social cognition - thoughts and feelings that are largely outside of conscious awareness and control. Project Implicit is the product of a team of scientists whose research produced new ways of understanding attitudes, stereotypes and other hidden biases that influence perception, judgment, and action. “On Being” Podcast about Implicit Bias “The Mind Is a Difference-Seeking Machine” an interview with Mahzarin Banaji, co-author of Blindspot: Hidden Biases of Good People. Romano, Max J. (2018) “White Privilege in a White Coat: How Racism Shaped My Medical Education.”?Annals of Family Medicine, vol. 16, no. 3, pp. 261–263.Inspired by the work of Peggy McIntosh, who cataloged the contents of her “invisible knapsack” of unearned white privilege, the author of this article highlights some of the ways unearned privilege in medical training is accrued as a consequence of having white skin color. “The Nocturnists” is a podcast where doctors share stories from the world of medicine.The Nocturnists Episode 1: Recognition Ben Lerman, an emergency medicine physician, describes how his ability to empathize with his patients deteriorated throughout his medical training, and how a chance encounter with a patient outside the hospital helped set him back on track.Understand the history of racism and healthcare in the US. Propublica Video “The US Medical system is still haunted by slavery”UW Medicine Slideshow “History of Unequal Treatment”Southern Poverty Law Center’s Pocket Guide “Speaking Up When You Hear Bias and Bigotry”: Includes examples of how to effectively Interrupt, Educate, Question and Echo in interpersonal situations involving bias and bigotry. Healthcare systems changeQuality Improvement (QI) interventions within healthcare systems should be informed by strategies and resources listed in all other categories. The following are current programs and initiatives as well as resources and recommendations for implementing and improving existing programs, or introducing new models and provider roles within healthcare systems. The Alliance for Innovation on Maternal Health (AIM) is a?national data-driven maternal safety and quality improvement initiative?based on proven implementation approaches to improving maternal safety and outcomes in the U.S.?AIM works through state teams and health systems to align national, state, and hospital level quality improvement efforts to improve overall maternal health outcomes. Learn how your healthcare system is involved in AIM’s work, and if they are not a part of the community, advocate for their involvement. Howell, Elizabeth A., et al. “Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle.”?Journal of Midwifery & Women's Health, vol. 63, no. 3, 2018, pp. 366–376.This concept article provides background material for AIM’s Reduction of Peripartum Racial and Ethnic Disparities Patient Safety Bundle, the use of which is designed to reduce racial and ethnic disparities in perinatal outcomes. “The goal of equity in care and outcomes can be accomplished only if it is treated the same as the goal of other quality improvement initiatives, namely, as a desired end in and of itself, embedded within a culture of safety that is specifically acknowledged, discussed, measured, monitored, and the subject of continuous quality improvement efforts.” Maternal Mortality Review Committee (MMRC) process recommendations: A pregnant person’s race, independent of other factors, can increase their likelihood of poor healthcare outcomes largely due to racism within healthcare systems. Consider including standardized questions when reviewing cases where a person identified with a race and/or ethnicity that is most impacted by persistent perinatal health disparities, such as Black, AI/AN and/or Pacific Islander. Include the addition of Race/ethnicity as a contributing factor when using the MMRIA MMRC Decisions Form, as well as the question, “Did racism contribute to the death?” Include a follow up question similar to the ones under homicide, “If racism contributed to this death, what was the race/ethnicity of the decedent?” Potential questions for discussion might include “Was racism present for this patient at any contributing factor level? If yes, describe how. If this person had NOT been from a racial/ethnic group most impacted by perinatal health disparities, might the outcome have been different? Why or why not?” Refer to the MSS prenatal screening tool for definitions of races and ethnicities included under risk factors, and examples of other risk factors used in their screening process. Advocate for these changes within MMRIA.Increase representation from racial/ethnic groups most affected by perinatal disparities on the WA State MMRC and on the WA State Perinatal Collaborative (WSPC), the workgroup for the MMRC. Membership on the WSPC is open to anyone with an interest in improving the health and healthcare of childbearing people, newborns and infants in WA state.Consider altering the definition for the “Cultural/Religious” Contributing Factor Description, when used by the MMRC, to reflect how racism and implicit bias affect the delivery of optimal care in healthcare systems, without implying the culture and/or religion of a patient was to blame for the death. Advocate for this change within MMRIA. The California Maternal Quality Care Collaborative (CMQCC) is a multi-stakeholder organization committed to ending preventable morbidity, mortality and racial disparities in California maternity care.?The California Birth Equity Collaborative is a CMQCC quality improvement initiative to improve birth care, experiences and outcomes for, by and with Black mothers and birthing people in California.?Over the course of the 2-year pilot initiative, the goal is to partner with community stakeholders and hospitals in the development and testing of multiple quality improvement interventions, and will conclude with the development of a toolkit reflecting learnings. “UnitedHealthcare, AMA unveil more medical codes for social determinants”, article from Modern Healthcare, April 2019. The proposal would add 23 more codes for providers to document a “patients' social determinants in a standardized way, which would allow them to better tailor care plans or refer patients to community organizations that could meet those social needs.”“Reproductive Injustice: Racism, Pregnancy, and Premature Birth” by Dána-Ain Davis- Published in 2019, this book is a troubling study of the role that medical racism plays in the lives of black women who have given birth to premature and low birth weight infants. “Medical and health professionals must look racism in the face and question the ways that the system within which they work might contribute to racist outcomes, draw from racist discourse, or perpetuate racist ideas. To move closer to reproductive justice, we must address medical racism. It is in fact possible, if there is the will.” Howell, & Zeitlin. (2017). “Improving hospital quality to reduce disparities in severe maternal morbidity and mortality.”?Seminars in Perinatology,?41(5), 266-272.This article provides an overview of research demonstrating how hospital quality is related to maternal mortality and morbidity, discusses pathways and connections to disparities, and provides possible levers for action targeted on improving hospital quality. Mann, S., Hollier, L., McKay, K., & Brown, H. (2018). What We Can Do About Maternal Mortality — And How to Do It Quickly.?The New England Journal of Medicine,?379(18), 1689-1691.Article and audio interview with Dr. Susan Mann. Recommendations include The Maternal Health Compact which ensures readiness by formalizing existing relationships between lower-resource hospitals that transfer pregnant patients and referral hospitals. Dr. Mann also recommends ACOG and the American Academy of Family Physicians collaborate on an additional year of comprehensive training for family medicine physicians who are considering practicing obstetrics in rural areas.Integrate the Patient Navigator into Perinatal Healthcare Systems. Other healthcare specialties have successfully included navigators in their systems, including cancer care. Natale-Pereira, A., Enard, K. R., Nevarez, L., & Jones, L. A. (2011). The role of patient navigators in eliminating health disparities.?Cancer,?117(15 Suppl), 3543–3552. doi:10.1002/cncr.26264This article discusses how patient navigators are uniquely positioned to play an integral role in the changing environment of healthcare delivery by facilitating access to care, as well as addressing language and cultural barriers. Patient navigators can break through literacy barriers, build trust, reduce fear, and support the improvement of patient-provider communication.As technological options are explored for improving a patient’s access to healthcare, such as tele-phonics for interpretation services, and telehealth/ telemedicine care, Broadband availability for rural and/or low income communities should be a consideration, as well as ensuring a patient’s confidentiality when using public venues to access technology. Article about the value of interpretation services during perinatal healthcare, and new options for providing services to more people. Healthcare systems must take adequate steps to ensure that persons with limited English proficiency receive,?free of charge, the language assistance necessary to afford them meaningful access to their services.Divenere, L. (2017). The clear and present future: Telehealth and telemedicine in obstetrics and gynecology.?OBG Management,?29(12), 37.This article shares how ACOG telehealth task force leaders have explored the technology that might be applied in routine as well as specialized ObGyn care. A report from the task force is due in coming months, according to Dr. Lisa Hollier, former ACOG president. This resource list was conceptualized, written and compiled by Alissa Wehrman, a social work graduate student at the University of Washington in Seattle during an internship with the WA State Department of Health. All communication regarding this document can be directed to awehrman@uw.edu. Please share widely. August 23, 2019. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download