ACCESS Westside Healthy Start: Closing the Postpartum Care Gap

"We often hear moms of newborns say their focus needs to be on the new baby. We are here as a reminder to say, 'no we need you to focus on you,' and we are helping moms do just that," says Timika Anderson Reeves, PhD, LSW, Director, Maternal Child Health & Women's Health and Community Integration, Access Community Health Network (ACCESS), Chicago, IL. Within ACCESS' Obstetrics and Midwifery practice, Dr. Reeves oversees the ACCESS Westside Healthy Start program.

Healthy Start is a national initiative started in 1991 to improve health outcomes before, during, and after pregnancy with postpartum care offered up to 18 months for community's high-risk maternal health clients. Currently, Healthy Start supports 101 projects across the country including nine FQHC. Local projects provide:

• Prenatal and post-partum care, screenings, and referrals to services for depression and interpersonal violence
• Outreach and case management to link parents with social services and educational programming, such as parent skill building
• Public health services, such as immunizations and health education
• Continuing education and training on best practices for health center staff and community partners

For over 25 years, the ACCESS Westside Healthy Start program has served thousands of birthing people from some of Chicago's most medically and socially high-risk communities. The network's Healthy Start project serves on average 600 women (300 in prenatal and 300 in postpartum care) every year. Between 2022 and 2023, its obstetrics team completed 7,700 prenatal visits and 3,500 postpartum visits.

To provide enhanced support to clients including those in the ACCESS Westside Healthy Start program, ACCESS created several strategies to create stronger connections and continuity with birthing patients across the maternal health continuum. "The human connection made during the prenatal phase helps to strengthen our bond and engagement during the postpartum periods," says Dr. Reeves. These maternal health focused strategies include:

• Postpartum care management services - Community Health Specialists work with patients during the postpartum period to address SDOH challenges and other stressors common among higher at-risk moms.
• Establishing multiple postpartum patient touch points - Along with every well child visit, postpartum patients enrolled in the Healthy Start program also meet with a care team member. These touch points allow care members to conduct maternal depression screenings, establish a reproductive health plan, and reconnect patients back to their primary care provider.
• Preparing prenatal patients early for labor, delivery, and postpartum care - A nurse care coordinator begins working with high-risk prenatal patients (e.g. those with hypertension or gestational diabetes) during their second and third trimester to prepare them for labor and delivery. They also partner with them to transition care back to their primary care provider.
• Designing postpartum care plans - Whether patients are returning to school or work or staying-at-home, Community Health Specialists help postpartum patients navigate their needed services, and establish care plans, which helps them transition out of the Healthy Start program.
• Accessing patient benefits - ACCESS Patient Benefit Specialists and additional care team members support patients to leverage available maternal health resources.
• Hospital partnerships - By securing labor and delivery privileges at many Chicago area hospitals and utilizing the Care Everywhere Link to exchange hospital delivery data, patient information remains consistent through electronic health records.

"One thing we have learned is to leverage our partnership and resources. No one program can do everything, but as a strong care team we can do a lot," says Dr. Reeves. For example, in 2023, the infant mortality rate among their Healthy Start patients was 4.5 per 1000 births. The community area's death rates of newborns is 8.03 deaths per 1000 births.

With the support of a dedicated care team, the ACCESS Westside Health Start program is able to improve the health outcomes of both the mother and baby. They partner with community members to reduce infant mortality rates on the West side and empower families to create stronger, healthier communities.