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Community Health Workers as Health Coaches and Educators: A Multidisciplinary Demonstration Project for Women with Hypertensive Disorders of Pregnancy
Purpose Statement
The postpartum period has been described as the most neglected aspect of maternity care. In the postpartum period, chronic diseases such as hypertension and diabetes are a leading cause of hospital readmissions for women in the United States. Due to the precarious nature of maternal care management during the postpartum period, targeted interventions must develop robust models to identify points of care for women during this period. Many recommendations for improving the quality of maternal care involve generating a more efficient team-based maternal care workforce.

By utilizing a multidisciplinary team-based approach to provide patient-centered care, Emory developed a model to provide enhanced community health worker (CHW) support in the fourth trimester and beyond for postpartum women with hypertensive disorders of pregnancy (HDP). CHWs acted as liaisons between the patients/families and Grady-affiliated health centers. The CHWs also acted as health coaches to guide women through self-measurement blood pressure (SMBP) protocols and health education on lifestyle modifications. A multidisciplinary team of specialists in cardiology, obstetrics and gynecology, primary care, population health, mobile integrated health, and public health/data management developed a team-based care approach to support women with HDP in the postpartum period. The effort of this multi-year quality improvement demonstration project has achieved significant improvements in the postpartum care management of women with HDP who receive care in the at Grady Health System.
Dr. Modele Ogunniyi


Dr. Modele Ogunniyi is a Professor of Medicine and Master Physician with the Division of Cardiology at Emory University. She also serves as the Associate Medical Director of the Grady Heart Failure Program. After receiving her medical degree from the University of Ibadan, Nigeria, she obtained a Master of Public Health and a Certificate in Health Finance and Management from Johns Hopkins University. Her postgraduate training includes a preventive medicine fellowship at the Centers for Disease Control, residency in internal medicine at Morehouse School of Medicine, and cardiology fellowship at Vanderbilt University.

Dr. Ogunniyi’s research focuses on examining social determinants of health and eliminating disparities in cardiovascular disease, diversity in clinical trials, palliative care in heart failure, and cardiovascular disease in women. She is passionate about mentorship and creating equitable pathways to diversify the workforce in Medicine. In recognition of her efforts, she received the Emory School of Medicine Excellence in Diversity and Inclusion Award, the R. Wayne Alexander Research Mentoring Award and the American Medical Women’s Association INSPIRE Award.

She serves as Principal Investigator for several clinical trials and is on the advisory board for the Metro Atlanta Heart Failure Collaborative and the editorial board of Clinical Cardiology. She is an active member and volunteer of many professional organizations including the American College of Cardiology, American Heart Association, and the Association of Black Cardiologists, where she serves on the Board of Directors. She is a Fellow of the American College of Physicians, American College of Cardiology, and American Heart Association.

Dr. Ogunniyi serves/ has served on several national committees, including as Co-Chair of the National Hypertension Control Roundtable and the ABC Membership Committee and on the National Forum Advisory Leadership Council. She is also a member of the Cardiovascular Disease in Women and Diversity and Inclusion Committees of the ACC. She is the Vice President of Health Awareness Initiative, Africa, a nonprofit organization, whose mission is to promote healthy lifestyles in African communities by creating health awareness through screening and education.  
Leslie Marshburn


Leslie Marshburn is a healthcare strategist currently serving as Vice President of Strategy and Population Health at Grady Health System. Ms. Marshburn pairs her public health and business background to oversee programs and strategies designed to improve the community's health by increasing access to high quality care and addressing social barriers to care.

She leads a clinical operations team focused on providing care outside the four walls of the hospital including home-based care, remote patient monitoring and population health care management. Additionally, the population health team leads system-wide initiatives supporting Grady’s value based care contracts and Grady’s Community Health Improvement Plan. These initiatives include the development of community partnerships and cross-functional teams to address SDOH and improve quality.

Ms. Marshburn has a leadership role in Grady’s Food As Medicine partnership with Atlanta Community Food Bank and Open Hand Atlanta which created a hub of wellness on Grady’s campus in August 2020. Grady converted space that was previously occupied by a fast-food chain into a food pharmacy, teaching kitchen and healthy cafe (Jesse Hill Market). This collaborative effort raised $4M+ to support capital and programmatic costs to address food insecurity and chronic disease in our community. Ms. Marshburn also has a meaningful role in addressing the homelessness crisis in Atlanta as a member of the City of Atlanta Continuum of Care for homeless services governing council and managing partnerships with community-based agencies to support Grady patients experiencing homelessness. With her leadership, Grady is partnering with the City of Atlanta, Atlanta Housing, Partners for HOME, United Way of Greater Atlanta, and Mercy Care to address those homeless who are chronically high utilizers of emergency services, have a disability, and who meet Grady’s high utilizer definition.

In addition to her population health responsibilities, Leslie is responsible for organizing and managing the strategic planning efforts across the organization, including the development of service line strategic plans and directing the production of market and data analytics to support planning efforts.

Leslie joined Grady after 10 years of strategy consulting experience working with health systems to address enterprise strategy, ambulatory care, behavioral health, and value-based care. She holds a Bachelor’s in Science in Healthy Policy and Management from University of North Carolina at Chapel Hill and a dual Masters in Business Administration (MBA) and Masters in Public Health (MPH) in Health Policy and Management from Emory University.
Maria Perdomo


Maria Cristina Perdomo, BSN holds a bachelor's degree in nursing from Colombia and has worked in the Grady Women's Health Center for 14 years. She has received training in blood pressure self-monitoring (SMBP), motivational interviewing, SMART goal setting, nutrition, and addressing social determinants of health. She has an extensive background in women’s health education and is known for her dedication to empowering women through prenatal and postpartum education, lactation counseling, and family planning services. An expert in providing prenatal and postpartum care and childbirth classes, she provides support to the Hispanic community and strives to ensure culturally sensitive care for all patients.

She offers bilingual support and services to effectively communicate with diverse populations. Mrs. Perdomo is passionate about community outreach and engagement, and she is adept at planning and executing community initiatives to raise awareness about health issues and available resources. She is the lead community health worker for our multidisciplinary CDC-funded demonstration project to provide enhanced postpartum support for women with hypertensive disorders of pregnancy. She serves as a health coach, health educator, and healthcare navigator. She teaches blood pressure self-management skills during home visits and addresses social determinants of health such as access to food and transportation, financial stability, exercise, nutrition, and healthcare access by connecting the mothers to community resources.
Janae Johnson


Janae Johnson is the Medical Social Worker for the Mobile Integrated Health Team at Grady Health System. Janae holds a Bachelor's of Social Work from Shaw University in Raleigh, North Carolina and a Master of Social Work along with a certificate in Non-profit Management and Leadership, grant writing, from the University of Georgia, Athens Georgia. Before leaving North Carolina Janae gained a background working in the Public School system, the Department of Family and Children Services, and the Public Health Department. Janae has a commitment to serving the community and providing a service of excellence. Although Janae is a native of North Carolina she has brought the same passion and desire to help others to Georgia and to Grady Health System.

She has brought her expertise to Grady, working on new grants from the ground up. She has served as a Community Health Worker for 5 years in Women Health Services on two separate grants. She has provided patients with prenatal and postpartum education, SMART goal setting, connecting not only patients, but families to community resources, navigating the healthcare system, pushing patients towards economic stability, and more. Throughout Janae's time at Grady, she has been trained in Trauma Informed Care, Mental Health First Aid, blood pressure self-monitoring (SMBP), motivational interviewing, SMART goal setting, nutrition, and addressing social determinants of health. Janae has and will continue to make a different in the lives of the population served at Grady Health System.
Elianna Paljug


Elianna Paljug is currently a Clinical Research Coordinator II at the Emory University School of Medicine where she serves as the main project manager on the discussed project, which involves overseeing evaluation activities, leading graduate student assistants, and guiding the daily operations of the Community Health Worker demonstration program. Elianna recently graduated from the Emory University Rollins School of Public Health with an MPH in Global Health where she completed her Master’s Thesis on the qualitative analysis of this work. While a student she also worked for the Task Force for Global Health as a quantitative data analysts and monitoring and evaluation specialist. She also holds an MS and BS in Biomedical Engineering from the Georgia Institute of Technology and began her passion for maternal health while conducting maternal health research through these programs in Addis Ababa, Ethiopia. Elianna has previously been selected for the Center of Disease Control’s prestigious Evaluation Fellowship.
Summary
Availability: On-Demand
Expires on Jun 05, 2027
Cost: Non-Member: $67.50
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Credit Offered:
1.5 CME Credits
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