Hi everyone, we were just letting people log on, but we will begin shortly. Thank you for joining us. Okay, welcome everybody. I think in the interest of time, we will get started. Hello everyone, and welcome to this live session titled Community Health Workers Has Health Coaches and Educators a Multidisciplinary Demonstration Project for Women with Hypertensive Disorders of Pregnancy. This webinar is hosted by the American College of Preventive Medicine. My name is Dr. Modele Oguniyi. I'm a professor of medicine with Emory School of Medicine Division of Cardiology and an attending cardiologist with the Grady Health System. I'm also the principal investigator for the demonstration projects that we'll be sharing with you today. As a preventive cardiology, my clinical practice as well as research focus really borders on examining and eliminating disparities in cardiovascular disease, addressing social determinants of health and championing equitable cardiovascular care for all. With support from the ACPM through a multi-year cooperative agreement with the Centers for Disease Control and Prevention, specifically located in the vision of heart disease and prevention, we designed and implemented a patient-centered care model in partnership with Grady Health System to address the morbidity and mortality related to hypertensive disorders of pregnancy during that critical fourth trimester, during the postpartum period. We define our fourth trimester as 12 months after delivery. And this program was focused on minoritized ethnic and racial women, predominantly black and Hispanic women. Along with our colleagues at Emory School of Medicine, Emory School of Public Health and Grady Health System, we are honored and pleased to share this work with you and highlight the important role that community health workers and team-based care play in postpartum management of hypertensive disorders of pregnancy. So as we begin, I will turn it over to my colleagues to introduce themselves. Leslie. Thank you, Dr. Oguni. Hi, everyone. I'm Leslie Marshburn. I'm from Grady Health System and I serve as the Vice President of Strategy and Population Health and have supported the implementation of this project at Grady. Maria. You're muted. I'm sorry. My name is Maria Cristina Perdomo. I'm community health worker. Janine. Hello, I'm Janine Johnson. I'm community health worker with Grady. Elena. Hi, everyone. My name is Eliana and I'm a clinical research coordinator and project manager for this work as well as an evaluation specialist. Next slide. So we have no conflict of interest or disclosures related to this presentation, but we must acknowledge the support of the American College of Preventive Medicine through a cooperative agreement with the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services. I must also disclose that the contents are solely our responsibility and do not represent the official views nor an endorsement of CDC or HHS or the U.S. government. Next slide. So we hope that over the next couple of minutes, we can achieve the following objectives, identify and describe how social determinants of health impact women in the postpartum period. We also wanna share with you strategies to provide patient-centered care for women affected by hypertensive disorders of pregnancy. And most importantly, to describe with you our process, our demonstration project that details how community health workers participate in the care, the postpartum care of women with HDP. Next slide. So May is a really important month for increasing awareness about hypertension or high blood pressure. It turns out that May is the hypertension awareness month or May is also referred to as the high blood pressure education month. But it's also preeclampsia awareness month. And this year, the theme for preeclampsia awareness month is predict, prevent and prevail. And as you can see on this slide, high blood pressure happens in one in every 12 to 17 pregnancies in the United States. Next slide. So why are we here today? Hypertensive disorders of pregnancy are the leading cause of maternal morbidity and mortality in the United States. They are part of what we call adverse pregnancy outcomes. And to talk about the magnitude, they occur in approximately 15% of all pregnancies. This data is coming out of the latest data from the Centers for Disease Control. They publish a weekly morbidity and mortality report. And in 2022, from the data that I will share with you soon, it was shown that HGP, which is hypertensive disorders of pregnancy, occur in 15% of all pregnancies and account for 7% of maternal death. We're all here today because we're champions of promoting equitable care for all. But sad to say, disparities still exist. And the groups that are disproportionately affected by HGP include Black women, American Indian, and Alaskan Native women, women that live in rural areas, low-income women, and older women. And of all these groups, in addition to having worse outcomes, Black women especially have worse maternal and fetal outcomes. These outcomes really constitute a public health crisis and reflect the impact of social determinants of health and other systemic factors. Next slide. So what do we mean when we say hypertensive disorders of pregnancy? I wouldn't bore you, but I will say that it includes chronic hypertension, which is elevated blood pressure, hypertension that exists before pregnancy, gestational hypertension, which is new onset hypertension that develops during pregnancy. And when we talk about preeclampsia, it just means hypertension diagnosed after 20 weeks. But in addition to that hypertension, there's evidence of proteinuria, which can be defined by greater than 300 milligrams of protein on a 24-hour urine protein collection or 0.3 milligrams on a point-of-care sample. You can also have preeclampsia with severe features. And with that, you have proteinuria and end-organ injury that can include elevated liver enzymes, elevated LDH, headaches, just evidence of end-organ injury. And when we talk about eclampsia, it just means symptoms, signs of preeclampsia are present. And in addition, there is seizure activity. Next slide. So this is the MMWR, the Morbidity Mortality Weekly Report that is put out by the Centers for Disease Control. It was published in 2022 by Ford and colleagues. And in this report, they use the National Inpatient Sample to examine the prevalence of HDP. Starred on this slide are the groups that are disproportionately affected by any hypertensive disorder of pregnancy. So as you can see, when we look at maternal age group, older women, especially women who have pregnancy within the age of 45 to 55, have the highest prevalence of any hypertensive disorder of pregnancy at 31%. When we look at race and ethnicity, you can see that the Black women have a prevalence of 21%, and American Indian and Alaska Native women have a prevalence of 16%. Moving down to analysis by county level, women who live in rural areas have a prevalence of about 15.5%. And when we stratify by income level, a measure of socioeconomic status, women in the lowest quarter, which is a median home income level of less than 45,000, they have the highest prevalence of HDP. And people say, maybe your healthcare is not defined by your zip code or where you live, but it was shown from this study that women who live in the Midwest or in the South where Grady is located have the highest prevalence. In fact, this data really resonates with us at Grady because we are in the South, there's the highest prevalence of hypertensive disorders of pregnancy. Next slide. From the same report, you can see that over the two-year period, the prevalence is going up. So when you look at any HDP, you can see the prevalence going up from about 13% to about 15.5%. Any HDPH here refers to pregnancy-associated hypertension. Going to the next slide, mortality, you can see over more than 30%, 31%, you can see the mortality rate for any woman that has hypertensive disorders of pregnancy. Next slide. So what are some of the contributing factors or what are the major contributing factors to this disparity? I know most people on this presentation are familiar with this slide, but I always like to lay the foundation. This slide comes from the Healthy People 2030, which is a set of national objectives put out to cover a 10-year period by the Department of Health and Human Services. So briefly put, social determinants of health are the conditions in the environment where people are born, live, learn, work, play, worship, and age. And this social determinants of health affect a wide range of health, functioning, and quality of life outcomes and risk. And to my right, you can see the domains of social determinants of health. So access and quality of education, access to healthcare and the quality of healthcare received, economic stability, social and community context, and the neighborhood and built environment. Next slide. And why do we care about social determinants of health? As we think about social determinants of health, most healthcare providers, clinicians on this call, we spend our time in healthcare and clinical care. But as a determinant of health outcome, healthcare is only responsible for 20% of health outcomes. What really drives the majority of health outcomes, 80% is the physical environment and social determinants of health and behavioral factors. And that is why a project like this is very important. Next slide. So as we think, I know that this presentation is focused on the postpartum period, but I wanted to put in this slide by Han et al, and not Western, to emphasize that really the impact of cardiovascular health starts from the pre-pregnancy period. And I think that as we think about interventions to improve the overall cardiovascular health of women, we need to start right from birth, going through early childhood pre-pregnancy. And I would encourage you to look at the Life's Essential It's, which really focuses on healthy living for everyone. But not to forget, if you look at the bottom of this slide, as I mentioned before, that the reason we have disparate maternal outcomes has to do with the adverse social determinants of health as well as other systemic factors. So we're not gonna cover this, but we should keep in mind that the fundamental or the foundational departments of cardiovascular health include the impact of stress and resilience, social determinants of health and structural policies that really determine how women obtain optimal cardiovascular health. Next slide. So why do we care about adverse pregnancy outcomes? As I mentioned earlier, HDP is just one adverse pregnancy outcome. Others include diabetes and some fetal outcomes. So this paper put out by Wu et al, in this paper they conclude that we don't know whether the adverse pregnancy outcomes lead to future, we know that they lead to future cardiovascular risk, but is it because of the adverse pregnancy outcomes, do they expose the future cardiovascular risk that women were predisposed to or because they develop adverse pregnancy outcomes, their risk is increased. But what we do know is that adverse pregnancy outcomes, including hypertension have cardiovascular disease consequences. So the effect on the heart, they can result in left ventricular hypertrophy, diastolic dysfunction, sin and echo, decreased arterial compliance, endothelial dysfunction, premature heart disease, coronary calcium and stroke. And there are a lot of trials and studies going on to really understand the pathophysiology. Next slide. So this publication about a year ago by the US Preventive Services Task Force, really they put out guidelines for how clinical practice and screening should occur. And last year they put out a recommendation to say that in asymptomatic pregnant persons, they should be screened for hypertensive disorders with blood pressure measurements throughout pregnancy. So any pregnant woman who goes for their visit should be screened for blood pressure. And in this paper, they also talk about the pathway to benefit. And the benefit of screening is that it's not only important to screen this pregnant woman with blood pressure, but this woman must receive evidence-based management of hypertensive disorders of pregnancy. I'll encourage you to read this paper. Next slide. So this recent review, excellent review by Radpaver et al in the Journal of American College of Cardiology Advances, really talks about taking care of the patient right from pre-pregnancy. And we are, this webinar is supported, is sponsored by the American College of Preventive Medicine. So a lot of our focus will be on prevention. So as we think about patient care, we have to start right from the pre-pregnancy stage, antepartum and postpartum. And for clinicians on the webinar today in the pre-pregnancy period, it's important for us to identify patients at high risk. So maternal age greater than 35, a history of prior eclampsia, a patient with chronic hypertension, diabetes, thrombophilia, autoimmune disease, obesity, and smoking. These are patients who are at high risk for developing HDP. And it's important to work with the patient to optimize maternal health before pregnancy. Awareness, awareness, awareness. It is very important to increase awareness. I know I come, when we conduct visits, I had a patient who told me recently last week that when she went to her PCP, her PCP was like, well, your blood pressure is normal. I don't know why you were sent here. So there's not only increasing the awareness of the patients but of the healthcare team. Most clinicians are not aware that the fact that the patient had pre-eclampsia or hypertensive disorders of pregnancy, it increases their risk for cardiovascular disease three to four times. So it's important that we continue to educate our colleagues as well as patients and empower patients regarding their health. Self-care strategies, as we'll highlight in our presentation is very important. And in the antepartum period, ensuring that their regular OBGYN visits. And as you think about this, mothers who are dealing with different issues, they are caregivers, not only for their newborn baby, they may have other babies, they may be caregivers for their parents. We need to think outside the box of how to make care accessible. Utilize telehealth services, remote monitoring of blood pressure, as we'll talk about. And the focus today, education and intervention for community health workers. In the postpartum period, you can read here, it's important that this woman receive a cardiovascular risk assessment. After they are connected with primary care, as well as an assessment with a cardiologist. Most practices are beginning to develop a cardio-obstetric clinic where these women are seen. It's important to continue monitoring. So the fact that self-monitoring of blood pressure were either in-person or a remote monitoring process if present. Also important to look at medications and to review symptoms, especially in that immediate postpartum period. Next slide. So what are the opportunities to identify and treat chronic hypertension in postpartum individuals? We're not gonna talk about all of this, but I show this slide to show you that it requires a multi-sectoral approach involving the community, the healthcare system, the healthcare professional, and even the patient. So working together, and as I mentioned before, the Life's Essential Eight. And as you can see in this schematic, it highlights the other APOs, the Adverse Pregnancy Outcomes. So working together, and we'll highlight some of this during our presentation, those are the opportunities we have as healthcare professionals, as researchers, as public health experts to not only identify, but to treat chronic hypertension. Next slide. So it's a tripartite strategy, really, to achieve equity for women, equitable care for women with postpartum hypertension patients, and mothers with hypertensive disorders of pregnancy. Like I mentioned, I think working at Grady, we are always thinking about innovative ways to treat patients, and as well as to address barriers to care. So when you look at this schematic, today we're focusing on community health workers, but I want to also highlight for you that it's important to think about telehealth follow-up, especially for these mothers, like I mentioned earlier, that are taking care of their babies, and other children, and maybe caregivers, to think about how can we incorporate telehealth follow-up and make it accessible, especially to women in rural areas, or women, underrepresented women, who may not have access to this, and we'll talk about how Grady Health System has been a pioneer in doing this. Personalized care is very important. SMBP, Self-Measured Blood Pressure Monitoring, and not only to monitor the blood pressure, but there has to be a way we should, those measurements must be translated into action. That is, there should be a communication between the patient and the clinician, and employing this tripeptide strategy will lead to decreased outcomes, decreased hospital readmissions, and decrease both short and long-term complications. Next slide. So I'm gonna turn it over to my colleague, Leslie Mashburn, who is our leader at Grady Health System, that helps us translate all these ideas we have into reality, because without having that partnership, all this would not be possible. Over to you, Leslie. Thank you, Dr. Ogimi. I appreciate your comments, and always learn something when I hear you talk about this subject and others, so thank you. And thank you all for being here today. I'm gonna provide a little context of Grady, and so you can conceptualize how we implemented this program in our current environment. So Grady Health System is a safety net provider in Metro Atlanta. We are a level one trauma center, the only level one trauma center in Metro Atlanta. We have two academic partners, Emory School of Medicine, and Morehouse School of Medicine, where we train 25% of all physicians that practice in Georgia have been through our walls. We have a large hospital campus with 956 licensed beds, as well as seven outpatient centers, as well as a world-class center for HIV care. We also operate the EMS 911 response system for the city of Atlanta, which will be important when we get further down the line. In 2021, in the last reporting year, Grady spent $206 million on community benefit, or 21% of the health system's expenses. So we are dedicated to investing in care for those who do not have insurance for educating the community and teaching or training our learners. You can see our payer mix here on the slide. We do serve a large portion of individuals who do not have health insurance, which is 36%. Many of our moms that are in this program have Medicaid coverage, which is 22%, Medicare, 26%, and commercial, 16%. So for those who may not be familiar with Metro Atlanta, I wanted to share some images that provide a good illustration of the environment. So these three maps show the median household income on the left and shows the highest median household income zip codes in dark blue. The lighter shaded areas are the lowest income areas. Go to the next map, and this has the proportion of residents with health insurance. The darker shaded areas have a higher percentage of population with health insurance and those, the inverse, without. And in the last slide, you can see the darker shaded areas represents the proportion of the community that identify as black or African-American or non-white race or ethnicity. And you can see just the tail of two cities in terms of income, insurance, and race and ethnicity. Go to the next slide. You can see this overlaid on health outcomes or indicators related to health. On the left-hand side, we have diabetes prevalence for adults. The darker shaded area is over 13% of the population has diabetes. The middle graph, the life expectancy at birth. The orange areas indicate a life expectancy of less than 72 years, which as you can visually see are in the Southern portions of Fulton and DeKalb counties with the darker blue and greens representing higher life expectancy in the Northern part of the counties. And then one of our social determinants of health areas that we know is very highly linked to health outcomes is food access. So the orange areas indicate a USDA food desert. Notice almost all are in the Southern part of Fulton and DeKalb counties. And the next slide that we'll take a look at shows where Grady patients originate from. So this is slightly zoomed in, but the darker areas represent where more of our patients come from. We've also overlaid the top 20% most vulnerable census tracts within Fulton and DeKalb counties, which is the social vulnerability index published by the CDC. And this just paints a really good picture of the patients that we are serving come from communities that do not have access to healthy eating, have lower income, likely uninsured, already have other chronic conditions like diabetes and hypertension that make managing healthcare and their health status even more challenging. Next slide. So diving in a little bit further into the Women's Center population. Within the Women's Center, we serve, these graphs show race and ethnicity. We serve almost 80% of our patients identify as black or African-American, 15% other, 4% white and 2% Asian. And then on the ethnicity side, 86% non-Hispanic, 14% Hispanic. And in 2023, we had 3,200 deliveries at Grady and 40% of these moms had a hypertensive diagnosis. And this compares to 28% at other regional perinatal centers. Grady is one of eight regional perinatal centers in the state of Georgia. And we recently last month achieved a level four maternal level of care certification by the Joint Commission. So we see oftentimes the sickest of the sick moms that come from generally the metro area, but many from our primary service area in South Fulton and DeKalb. And 40% of our moms have inadequate prenatal care as defined by the adequacy of prenatal care utilization index, which means that they started prenatal care in month five of their pregnancy, or that their prenatal care represented 50% or less of the recommended number of prenatal visits. And for a full-term pregnancy, that's fewer than eight visits. Additionally, almost 20% of our patient population of our delivery population speak a language other than English, which makes these approaches with community health workers and additional supports really important so they understand the care and provide culturally competent services. We also see significant social determinant needs within our women's center population. And you can see the statistics here. We screen both in our ambulatory clinic setting, as well as in our inpatient setting for these needs. A 34% of the women's center population experienced financial resource strain in 2023, 27% experienced food insecurity, 16% housing insecurity, and 15% transportation needs. So as Dr. Ogany mentioned, we are really focused on the CHW component of the service that is provided to postpartum women with hypertensive disorders of pregnancy, but they receive a lot of unique support that is offered at Grady. And this graphic illustrates the multi-tiered intervention. So it starts really with when the mother comes to her prenatal care visits and in the hospital during delivery. We have a dedicated hypertension nurse navigator that works with the mom, make sure she understands, you know, the condition that she has, educating about signs and symptoms and reinforcing the need for self-management. We also provide blood pressure cuffs at that time. This navigator also helps ensure that the mom is connected to follow-up care after delivery. One of those components is through our mobile integrated health program. And you can see the team illustrated there on the slide. This is a service that is out of our EMS division and includes nurse practitioners and EMTs that go into the home and do provider level visits with patients post-discharge. We do see a broad range of patient types, but one of our dedicated protocols that we have is with the OB service for moms with hypertensive disorders of pregnancy. So within this protocol, we see moms with preeclampsia with severe features within three days of going home with baby. And if the mom has chronic hypertension or gestational hypertension, we see them within seven days of going home. We have a very robust plan for escalation and communication with the OB on-call service. And through that protocol, we are able to provide immediate release nifedipine in the home if the blood pressure is elevated, which we are really focused on timely treatment of hypertension at Grady, both in the hospital, but also making sure that that care is provided outside of the hospital after delivery. And I like to marry the discussion of this intervention with the graph on the right that shows the number of pregnancy-related deaths in the state of Georgia by the timing of the death. And as you can see, the largest bar is in the eight to 60 days postpartum. So we're really focused on that after delivery, what's happening with mom and making sure that she's checking her pressures and that we initiate care as fast as possible. And then as Dr. Ogany mentioned, we are very focused on making sure mom gets to the six-week OB appointment. We've introduced telehealth options and also our cardio OB service, making sure that moms get back into that clinic. And then the final piece, which is more longitudinal in nature, is the self-management blood pressure program with our community health workers for up to nine months, or excuse me, 12 months after delivery. And this program is really focused on resource connection, social support, and ensuring connection to care after the delivery. Next slide, please. So what is a community health worker? I imagine since you're joining this, you know what a community health worker was, but wanted to make sure we are all on the same page in terms of how we define a community health worker and certainly what that translates to on the ground at Grady. So we believe community health workers are a frontline public health worker, is a trusted member of the community, which is really key, and serves as a liaison between the patient and the healthcare provider, as well as any social service agency. It is important that the CHW provide culturally competent care and relate to individuals and help translate, which may sound like Greek, in a doctor's office to what is relatable to the patient. CHWs also build both individual or patient-specific capacity and also community capacity by increasing knowledge, sharing information, how to access services, what to do in certain instances, and that self-management component of health improvement. And this, we've adopted the definition from the American Public Health Association. We do have the next slide. We just wanted to highlight in the state of Georgia, we have a significant effort to advance the role of the community health worker within the healthcare setting and in the community. So we are active in the work in the state of Georgia. There are many different types of CHWs. What you'll hear about today is really a healthcare-based CHW role where we're following patients longitudinally and supporting them in their care, kind of going from the healthcare center into the home, but there are also many successful programs, and we promote many of these where the community health worker is embedded in the community, and then they bring health information to the community. So there are many different ways to implement CHW programs. And common titles, that's the other thing. Not every community health worker is called a community health worker. They may be navigators, health promoters, advocates, et cetera. So be on the lookout for any of those titles in your areas to take advantage of these types of services and supports. Next slide. And here you can see we have a day at the Capitol for Community Health Worker Awareness Day. This is from the day this year where many of our CHWs participated. And we did do some specific training for this program to make sure our CHWs, who you'll hear from today, were fully equipped to support our moms. They participated in the Department of Public Health core competency training program, as well as the Healthy Heart Ambassador training program, mental health first aid. And then we did custom training around motivational interviewing, nutrition training specific to pregnancy in the postpartum period, as well as other curriculum that was developed throughout the program. So hopefully you have a good sense of Grady's landscape and the environment. And I'll turn it over to Eliana to tell you more about the program design. Sounds great. Thank you, Leslie. So this program that we conducted at Grady had 70 participants who were Black or Hispanic women with HDP who delivered at Grady. And we had a lot of different components. Key was that CHW engagement, which we've highlighted as so important. The CHWs engaged with participants through home visits, phone calls, and texts. They also trained participants on how to use self-measured blood pressure devices. They gave them a validated device, taught them how to use it, taught them what the numbers mean, and helped them with logging their BP throughout the study period. They also provided nutrition education with things such as recipe books, and also partnering with local organizations to do cooking classes, and also provided social assistance to address these social determinants of health, which have been highlighted as so important. We also organized events to help participants with exercise through walking with the Atlanta Botanical Garden, which I saw that somebody recognized in our first photo, and also helping with healthcare navigation, which is so key to help with scheduling appointments, doing reminders, and accompanying patients to clinic appointments if the patient wanted to. So in order to do all this, it took a large team and a multifaceted team, and I thank all the people here, and I'm not going to name them all for time, but just wanted to highlight how many different disciplines we have among our PIs and among our public health and medical grad students that were so key in bringing all of this together to be successful. This is our project work plan that reviews one patient's journey through the program. So in the first phase, they're recruited at delivery, or right before delivery, identified as having HDP, and then would meet with the CHW to see if they were a good potential person for this program. In the first phase, weeks 1 through 12, we have that MIH visit, which Leslie described, where the team goes to the house, but the CHW would join that group or go slightly after and provide more education, more intervention. They would continue with weekly phone calls or home visits at the patient's preference, help the patient get back to the hospital if blood pressure levels are elevated, and also help schedule a six-week OBGYN appointment. In the second phase, we switch to biweekly phone calls and home visits with the participants as desired by the participant, and the CHW also assisted with scheduling a three-month PCP appointment and a six-month cardiology appointment. And then finally, in the last phase, most participants switched to more monthly communication with their CHWs, but the CHWs were still there for them, still collecting data and providing support as desired by the participant. And evaluation happened throughout this entire process, which I'll talk more about later. But first, I wanted to turn it over to the CHWs to provide a description of some photos that show these activities. And I wanted to share that all patient photos have been shared with written permission from the patient. Thank you, Liana. Home visit is, as a community worker, we do home visits. We go to their houses and we check their blood pressure, we give education, and we assist them to be sure they have the appointments ready, like postpartum appointment, cardiology appointment, or PCP, the primary care. In the home visits, which are really good moments, we have the opportunity to know patients, to know their challenges, to know their potentials, and of course, we have the opportunity to identify social determinants of health. We have the opportunity to give education and the patients enjoy it. It's something that we see the patients well receive, that home visits, they really enjoy, and they were really grateful for that visits. In this picture, we have a group, and in this group, we are visiting one of the patients who were sick, and we're doing community. We even, with this group, we have a WhatsApp group, and we enjoy. We enjoy the birthdays, we go to cook together. It was a really good experience with these patients, yeah, and a patient-likes home visit. Next, Cecilia. And here, we have one of our cooking classes. Here at Grady, we have a food as medicine program, and they do a food pharmacy, and they offer cooking classes to our patients, our Grady patients who have chronic hypertension and diabetes, and they were so gracious to allow us to use their cooking facility for our program. So, we brung in our own instructors. It was our Grady WIC program manager and one of our lead dieticians. Patients were able to come in and use items that come on their WIC vouchers to learn how to cook in healthy ways with low sodium. They were able to discuss and learn how to use the food labels, nutrition labels on the back of food. They were able to not only see the demonstrations, but to participate and cook themselves. So, they love the cooking classes. Next slide. Maria. Oh, this is a botanical garden in Atlanta, and it's a really nice place, and it's one of the activities that patients like. We try to register patients to go to a gym, but I don't know. It was not well received, and we decided to go to the botanical garden for a walk-in, and they enjoyed it. It was a really good experience, and the patient, it was not just a physical activity. It was a holistic experience promoting health and community, and something we liked is the family. The family was there, and they enjoyed with the family. It was a really good activity, and even the patients called me to say, okay, when is going to be the next visit, and they enjoyed. They want to go to the botanical garden, and this is a really nice experience for them. It was a really good one. And here is our Mother's Day event we hosted. We wanted to do something for our patients to get them all together. Oftentimes, our patients are, it's just us and the patient, so community health worker and the patient. So, this gave them opportunities to come in to Grady. They were able to speak with the doctors, ask questions, and they were also able to meet one another, share each other's, you know, issues or life stories. They were able to change phone numbers and email addresses, and like Maria said, ultimately came to them building their own community. Like they were, it built like relationships. To this day, they're still like contacting one another, not only about hypertension, but just in general, they built like a great community amongst themselves. Next slide. And here is the program graduation certificates. So, it is hard for any of us to break old habits, things that we're used to doing year after year, all our lives, and now to come in, like make sure you take your blood pressure, make sure you take your medication every day, make sure you go to your appointment. So, we wanted to let our patients know that we recognize and we saw the change, and we granted them with certificates of completion from the program. Next slide. Great. Thank you so much, Maria and Janae. I love hearing from both of you about the experiences with the patients. So, this slide describes our three-pronged evaluation approach. Firstly, of course, we're collecting blood pressure measurements, seeing how those blood pressure measurements change throughout the study period. Participants would measure their blood pressure at home, but we also looked at blood pressures from office visits and extracted those from the EMR. For quantitative, we did surveys at baseline, midline, and endline that covered a large number of domains, both in terms of perceived levels of health, stress, physical, mental health, but also diet behaviors and shopping activities. And then we also wanted to do a mixed method approach and so made sure we had a strong qualitative piece of this evaluation. We did CHW and participant in-depth interviews at midline and endline, talking about their experiences, motivators, barriers, and the overall impact of the program. So, this project, I should say, is in progress. So, we are wrapping up actually this month, and we'll be really excited to share all of the results from this in the coming few months as we write it all up and look at all of our data. But I have some initial data to share. So, we had 70 participants, as I mentioned, enrolled over one year with 14 lost follow-up. We had 69% Black and 26% Hispanic participants. The age range is 17 to 45, and 69% were on Medicaid and 19% uninsured. Among the first 30 participants, we did see that BP declined significantly from enrollment to follow up, and also that the no-show rate for postpartum visits improved to only 28% no-show compared to over 50 for the hospital's general postpartum population. Looking at those blood pressure measurements a little bit more closely, we had around 1,400 readings. We saw that two-thirds of patients in that first 30 had a decrease in blood pressure over a 44-week follow-up period. There was an average change. And I think this is really interesting. We had a large range of different types of behaviors with blood pressure monitoring. So, some people took blood pressure measurements less than 10 times throughout the program, so that's about once a month. Some took it nearly every single day, over 50. So, we can separate into less than 10, 10 to 50, and over 50 as even groups. And then we did see that among those that took more blood pressure measurements, their decrease in BP was significantly more compared to the other groups. So, these are just preliminary results. Again, we'll see, but it shows the range of experiences and positive impact of the program so far. Looking at qualitative, the interviews really described how the interactions with the CHWs increased their motivation to measure BP, their understanding of the importance and knowledge of measuring BP, and also adherence to all these management behaviors and medication that we've talked about. I conducted these interviews as a part of my master's thesis and was very struck by how often the participants said, oh, I just love Maria. I love Janae. They're so nice. They're so supportive. They're there for me. And that really goes to show the amazing personal qualities of our CHWs, and also how their professional backgrounds in nursing and social work before they became CHWs enabled them to be such great resources for our patients. In the next round of interviews, these were the broad themes that were apparent, and I'm going to go a little bit quick, but they talked about the CHWs' impact and role, how they made healthy lifestyle changes through the program, how their motivation and engagement was impacted by the program and the CHW support, and in general, about the resources and support of the program. And in the patient's words, I wanted to provide some quotes. So this first patient describes how she had a baby before the program and is juxtaposing that with her experience now. So she said that sometimes she would feel down and weak in her first delivery, but she didn't know why. But through the CHW's education, she realized maybe that was what was happening in my first pregnancy experience. And she also describes that now she doesn't feel like she doesn't know what's going on anymore, which is a scary experience for a new mother, of course. She also describes that now she understands she doesn't just need to take care of her baby as she thought in her first pregnancy, but I need to take care of my baby and me. So she says we go for walks in the park, we eat more healthy, and all these things that have helped her in the postpartum period. This patient says very frankly, which we appreciate, that if she didn't have the support of the CHW's, I wouldn't have attended any appointments, honestly. And she also talks about the impact of the cooking class. So now I take more care of what I eat. I eat more vegetables. Because of that cooking class, she learned a lot. She feels happier, more active, is walking, and sees that lifestyle change in the reflection of her blood pressure reduction. And then finally, this person describes how now that she has knowledge about her health through the program, she can help her family with their high blood pressure problems, if they have any, to know what the symptoms are and all this. And then also she describes, yes, I didn't even know if it was high or not before I was in the program, but now I'm diligent about checking it. The program has made me realize how crucial it is to take care of my health and lead a healthy lifestyle. So in the participants' own words, we can already see the great impact of the program. As we went, we tried to address issues that came up through the program. So we noticed that there was a high burden for managing a BP log that is paper. So we did pilot a Bluetooth blood pressure device element for some participants that was corresponding with an app where they could see their blood pressure measurements automatically. And this was really successful. All participants really liked the Bluetooth monitor. And this helped inform the Grady Remote BP Monitoring Program, which is starting soon, which Leslie can provide more details about. We also, as I mentioned, did these cooking classes due to a description from participants of describing the difficulty of implementing the different behaviors that they're learning. So these health cooking classes could be tailored to the population. Some of these classes were conducted in Spanish with Hispanic food, which really ensures that the lessons are valuable for patients. And then finally, appointment adherence. It has been a persistent challenge for patients. So we try to move as many visits as possible to be virtual with both virtual PCP, but also cardio obstetric appointments. And then if the patient's in need, they can come back in. So this is a big overview of the evaluation so far. Next, I would love for all of our team members to come on camera and we'll go through some reflections from the different members of our team. So I think first up is Maria. Okay. I have been enjoying the community, working as a health community, and I learned a lot from patients. And this has been a really remarkable experience with a meaningful impact on the patients. And it was a great opportunity to identify social determinants for too many patients. We have seen the family, sometimes family is with the patient, but sometimes we need to have more education to involve the family, to help the patient to cook and change the eating habits, like start all the family eating low-sodium food, less processed food, walking or exercise together, and adopting healthier lifestyles. We can empower patients through this program by giving them tools and resources to share with the family and community. We have a diverse group, and considering cultural backgrounds is really important to foster better engagement and improve health outcomes. Sometimes it's difficult for patients to remind or sometimes they don't see the importance of self-care. We have a lot of disappointment, and sometimes patients forget to take their medication, and I think we need to focus more on giving more education on self-care. It's really important for them. And for some patients navigating the financial assistance process, it was cumbersome. For some people, like people who don't have insurance and they need to find all the documentation they need to apply, for some patients were not really easy. We get it. Next. All right. Many of our patients were educated and understood their diagnosis not only affect them but the people around them. That's just like the quote that Ileana said, the patient realized she had to not only focus on her baby but herself as well. Some of our patients have never set goals before, so this program gave them an opportunity to set goals and follow through. When you're speaking to them, it's never been a time that they say, I'm going to do this and this is how I'm going to get to it. So it was awesome to see them set goals and to actually make those goals. So there were some changes in behaviors with patients as far as the frequency of their monitoring of their blood pressure. Once they got their Bluetooth monitor, where a patient may have been submitting one blood pressure a week or one blood pressure of the week, they will ramp up to maybe submitting two or three throughout the week or two. And no matter how many times you educate or give patient information, there's always going to be some patients who are going to underestimate the severity of their health condition. And, you know, that's just the nature of healthcare. Some patients are going to want to jump on it and some patients are going to fall by the wayside. And stresses of life, like job insecurity, stable housing, other small children in the home, may play an important part about how patients participate and how involved they were in the program. They may feel like they have other things that, you know, kind of trump what their healthcare needs. Leslie. Thank you, J'Nai and Maria. Some things that I have been thinking about, about this program is that, you know, Grady had never, you know, continued engagement with moms after the postpartum period. So, for me, thinking about what we need to do differently or how we support families, it gave us a better understanding of the patient's barriers to care and of the patient's barriers to care after delivery. So, we knew we had a really high, you know, six-week OB no-show rate, but, you know, this gave us a really intimate understanding of what the barriers were so we can better address them. And I am just taken aback by the sense of community that was created between the patients and the CHWs. It was, you know, something I didn't really anticipate when we started the program, but it makes me feel good and I know there were some really positive outcomes from that. In terms of managing a program like this, and for anyone who wants to support CHWs within the context of a health system, it's really important to have the right person supervising those individuals. And, you know, oftentimes when we develop innovations in a health system, it's, oh, well, this person can report to this person and they don't truly understand what the CHW does or the role. And it requires a lot of trust and experience and being able to supervise kind of a non-traditional healthcare role because the individuals serving in these roles, they're going into homes, they're working off the hospital campus the majority of the time. So having flexibility and understanding the supports that the CHWs need. I mean, oftentimes they're exposed to, they become invested in these patients and when bad outcomes happen for an individual, whether it be someone loses a job or things that happen in life can affect the CHW. And so making sure they're getting the support they need as well as the space to do what they need to do to make the program successful. And then there's also a need to constantly educate and talk about what the role of the CHW is. It's not just a social worker that's filing the DME paperwork. This person is really their advocate and sharing with other care team members what their role is will help build trust, increase the use of the CHWs and help promote this in the future. And then our pilot with the Bluetooth-enabled blood pressure cuffs was really eye-opening. Everybody has a hard time doing something consistently, writing in a journal, meditating, whatever the thing is that you're doing, but for women to sit down and take their blood pressures and write it in a manual log, we saw such a big increase with the Bluetooth-enabled devices. It really made us expand our program with our existing remote patient monitoring programs to this patient population, and then stress the importance of making sure that program was integrated with our EMR. So we now have, we went live in April with our existing patient populations where that information is directly fed into Epic, which is a total game changer. And then we have plans to expand that service to our patients with hypertensive disorders of pregnancy later this year. So we're really excited about that. And without this program, I don't think we would be where we are now, so. Back to you, Dr. Oguni. Yeah, so thank you all for working this journey with us. And just to summarize, our preliminary findings suggest that in the postpartum periods, community health worker programs can be a feasible and culturally acceptable method to support hypertension management in safety, net, or low-resource healthcare settings. As you can see, our community health workers serve as health coaches, health educators, and they play a key role in addressing social determinants of health. Of course, what we've presented today is a demonstration program supported by the Centers for Disease Control and ACPM. So we still need further research to evaluate the effectiveness of this community health worker support programs. And finally, hypertensive disorders of pregnancy are a significant contributor to maternal morbidity and mortality and the increased future cardiovascular risk. A multidisciplinary patient-centered and really family-centered approach that includes community health workers can be effective in addressing social determinants of health by providing that enhanced support that these mothers need. To advance health equity for these mothers, we need all hands on deck. A multi-sectorial collaboration that includes clinicians, healthcare systems, professional organizations that are patient-facing, community-based, medical healthcare advocacy, non-governmental, all organizations, all hands on deck. Of course, we always need a governmental agency and policy experts and other stakeholders. So thank you so much for your time. And to answer the question, oh, okay, I will talk about this slide. We already talked about this. May is Hypertension Awareness Month. So if there's something you learned from today, please make sure you share this that we need to achieve national high blood pressure control. The control rates are abysmal, 25% nationally. So all of us working together through advocacy, through prevention can achieve hypertension control. And especially for our mothers. And our last slide, finally. So to answer the question in the chat, this is actually a picture, and this picture warms my heart, of one of our mothers in the botanical garden here in Atlanta. And this was one of the walks coordinated by Maria and Janay. And just look at the joy, you know, holding up her baby. And I'm sure in the years when this baby grows up, she's gonna show this picture. So we can do this together. And we thank you for your time. And we hope that together, all of us working together, we can achieve health equity for all women with hypertensive disorders of pregnancy. Thank you. We will take questions. I think we have Leticia and Taha helping us moderate questions. Okay. Okay, well, a question is, how long has your postpartum hypertension program been active? Does this program include plans for sustainability and expansion? Leslie, I don't know if you wanna take that. How long has your postpartum hypertension program been active? And what are the plans for sustainability and expansion? So as I walked through the four different components, main components of what we do around hypertensive disorders of pregnancy, each one of those started in a different year, but it's been at least four years since we've had the navigator and the home visitation component. This program started two years ago, 2022. And we do have plans to continue this program through what I alluded to with the remote patient monitoring work. And we do plan to continue to take referrals for the blood pressure self-monitoring. And we envision having CHW support accompanied with that. We are working out a lot of those details on what that will look like, but we'll continue to look for outside support as well as internal support for the program. Thank you. I think this is also related to what you talked about. This question is from Dr. Wendy Book, who is one of my colleagues at Emory. She says, how scalable are the community health work programs to support a larger number of people? How scalable are these programs? I can take part of that, Dr. Oguni. I certainly think the Bluetooth blood pressure monitoring can be easily scaled to a large number of participants. And Maria and Janae will tell you, they spent a lot of time trying to get moms to take their blood pressures when we were doing it the manual way. And we saw the number of readings just skyrocket when we went to the Bluetooth device. So I think from that standpoint, you could scale more. For the highest risk moms and that personalized CHW lifestyle modification intervention, there is some limit to scalability of that. How many people can you get in a cooking class at one time or go on a botanical gardens walk? But certainly the blood pressure monitoring, I think you could do a little more at scale than what we've done in this demonstration project. And maybe it's just kind of identifying the people that really have that higher need and need more individualized care with some programming and education going out to larger groups at one time. Thank you, Leslie. And I know that for each community health worker, their load at a point in time is 30 patients, right? Depending on the risk. Another question, amazing work being done. Thank you for your dedication to improving patient experience and outcomes. Yeah, we're proud of our great team. Did the community health workers, and this is for Janae and Maria, do you feel that you had to spend more than 40 hours, the usual 40 hours to fully serve the mothers? How were you able to balance the workload and continue to be there for the program participants? So Janae and Maria, if you wanna take that. I don't think that I went over like the 40 hours. I will say there were times when, even though I'm a Monday through Friday worker, that I will check in on patients on the weekends because outside of community health worker, I'm a person who cares, so I'm just gonna do it anyway. But I wouldn't say that it was so demanding, even with the full caseload that you spend a lot of times like working over, no. And what was the second part of the question, Dr. Dolan, opening? How were you able to balance the workload and the needs of patients? And just like other programs, some patients do require more attention than others. So that kind of helps you balance it out because some patients, they are on top of it. They're just doing as they should. You don't have to remind them or stay on them as much, they're already sending their blood pressure measures in. They're already making it to their appointments and you're just calling, checking and some other patients have to have the extra push. So I think it kind of balances itself out. Maria, do you have any thoughts? Yeah, I agree with that. Yes, with some patients, you don't have to tell just once and they send you the BP log and they say, they participate really active, active. But yeah, it was not bad. I don't feel it was really hard work. I enjoyed it. It was a really good work for me. There's a question here that says, how often did your professional and community health worker meet to evaluate performance and establish curriculum activities for the program? Eliana, do you wanna speak to that a little bit? Sure, I can speak to it first and then Leslie, if you want to add on. I think Leslie and I both supported the CHWs in different ways. I was more on a day-to-day level with evaluation and just helping them with any needs that they had. We had students conducting surveys. So I would coordinate with the students to get ahold of the patients, ask the CHWs to help with compensation. So more of those like day-to-day things. We also assisted as we came up with new ideas. So for example, we came up with the idea as people finish the project to give them a lot of different materials that had community resources, hypertension education. So I worked with the CHWs to develop what those materials should be, what are the really key resources they share the most often. And I think as far as timing, we met at least monthly, usually twice a month, me and the CHWs every two weeks, just a touch base about everything. But we'd be in touch with phone calls as needed to address other things that came up. And Leslie, did you want to add anything to that? No, I think that accurately depicts, we had one standing monthly meeting with the, and I don't know if Dr. Oganee talked through this, but we really had a clinical lead or PI from cardiology, which was Dr. Oganee, Dr. Stacey Schmidt from Emory Internal Medicine, and then Dr. Victoria Green from Emory OBGYN. So it really was, as Dr. Oganee mentioned, a multidisciplinary team that was thinking about, hearing the feedback from the CHWs, seeing the results and kind of brainstorming what to do next. So that group met monthly, and then Eliana and I supported the team in various ways between those regular meetings. Yeah, and I think, I mean, those are very key points. Most of our meetings were troubleshooting, problem solving, and as fantastic as this program was, we did have patients who had adverse events. I remember a situation where a patient developed a stroke, and as Leslie talked about, just supporting and talking with the community health workers, reaching out to the patient and their family. And even though the patient had completed the program, we were looking, like the community health workers were invested, were able to connect with the teams, think about rehab for this patient who had a stroke, you know, and things like that. So I think that it was a continuous evaluation process, trying to like improve and solve barriers, solve problems on the go, but I am really proud of the team. You know, everybody, all our investigators, our students, you know, research assistants, everybody was truly dedicated and really had a passion for making sure this program was successful. And someone mentioned NDPP, oh, National Diabetes Prevention Program. And apart from the, they also, our community health workers received training on motivational interview training techniques. And I'm trying to answer the questions in the chat before I go to the hand that was raised. I think, I hope I got all the questions. I think Leslie- I still have one more question. Okay. I can read it out. It was- Yes, please. Oh, I just had it. From, oh, sorry. Oh, did someone ask- Some of the patients, okay, that one. Yeah, if some of the patients wanted to become CHWs, or was that a possible aspect to the demonstration project? So while none of, while this wasn't formally a part of the project, I was thinking, Maria, you could speak to how some of the patients kind of became leaders in their communities or with other patients, Rhea or Janae, because I know that that happens sometimes. I'll say this is, this work in this program was the third grant that I worked on here at Grady. And I have always had a patient asking me, well, how can I do what you're doing? Like they always just ask, want to help other participants or patients. I think one of the strengths of this program is that it built a peer support group. Like, as you can see from some of the home visits, there were different mothers, they became advocates for each other. So I think the sense of the community, the peer support mentoring, they provided each other under the leadership of the community health workers was a strength of this program. So in the eight minutes we have left, Bridget Smith, I don't know if you're able to be unmuted or if you still want to ask your question. I'm not sure whether participants can be unmuted. Bridget, do you still want to ask your question? Someone answered it for me in the chat. Okay, sounds good. And I hope I've answered all the questions, but if I have not, please feel free. We have eight minutes left, but I really want to thank you all for your active participation and for joining us today to learn about Grady, where Grady is the best place to walk. I think that walking at Grady, I trained at Grady as a resident of Morehouse and came back here after my training and really every day I come to Grady, it's exciting because it's always a way to think outside the box to provide equitable care. And we can't do it without our partners. I mean, Leslie, Janae, Maria have just been fundamental and also our other co-investigators who are either on the call or couldn't be in here, Dr. Green, Dr. Amy Gerard, who led the evaluation process, Dr. Stacey Smith and all our students. For me, I'm very passionate about mentoring and this process has really helped us to involve medical students, public health students, cardiology fellows, postdoctoral fellows. So it has really come full circle, equitable clinical care, research, scholarship, mentorship. And like Eliana said, we are looking forward to wrapping this up and publishing this very soon. So thank you all for your time. And in the absence of questions, we will bring this to a close. And I also want to express my appreciation to the Division of Heart Disease and Stroke Prevention under the leadership of Dr. Leticia Presley-Cantrell and her team, Ms. Kaha Mohamed and the ACPM team for their support, always responding to our questions, Kate, Anita, Carissa and everybody, because as you can see, it takes a multidisciplinary approach and developing partnerships to achieve equitable care for all. So thank you for your time and we will adjourn. Thank you.

Community Health Workers

Health Coaches

Educators

Multidisciplinary Demonstration Project

Hypertensive Disorders of Pregnancy

Postpartum Period

Patient-Centered Care Model

Social Determinants of Health

Minority Women

Self-Management of Hypertension

Health Equity

Collaboration