Supporting Transitions to Primary care among Under-resourced, Postpartum women: The STEP-UP

摘要 我们将测试技术支持的“阶梯式护理”策略的有效性和保真度， 在资源不足的社区卫生保健环境中，将高危产后患者送往初级保健。 妊娠期糖尿病（GDM）和妊娠期高血压疾病（HDP）分别占8%和14%。 虽然GDM和HDP通常在怀孕后解决，但患有这些疾病的女性 这些疾病的不良心脏代谢结果的长期风险仍然增加。因此，临床指南 建议既往患有GDM和/或HDP的产后个体从OB过渡到初级保健， 正在进行的评估和/或治疗。然而，研究表明，只有三分之一的女性患有GDM， 患有HDP的妇女在产后6个月内看初级保健提供者。在GDM患者中， 完成推荐的精神障碍测试。患者对心脏代谢风险的了解有限，较差 产科和初级保健之间的协调以及后勤挑战已被确定为障碍。妇女 黑人，西班牙裔和/或低收入，教育程度较低和/或健康素养较低的人， 接受后续护理。由于早期发现和治疗高血压和血糖异常可以减少疾病 进展、并发症和死亡率，护理过渡不佳是孕产妇保健公平的问题。 作为回应，我们将在资源不足、 产后妇女（加强）战略。STEP-UP利用可用技术支持 卫生中心，从产后产科到初级保健。具体而言，临床决策支持（CDS） EHR将促使提供者就初级保健过渡提供咨询;它还将使提供者能够订购转诊 并推荐血糖测试患者将收到语言一致的材料， 加强咨询，沿着短信，以激励和提醒他们安排和参加小学 关怀探访STEP-UP被设计成一种低成本和“低接触”的干预措施， 策略可能对大多数患者有效，但不会对所有人都有效。一种“阶梯式护理”方法， 可能有必要只对那些需要的人进行个性化的外联。因此，中央外联协调员 将提供额外的，基于电话的支持，为任何病人谁没有安排一个初级保健访问4 产后数月。我们将在4个大型安全网健康人群的阶梯楔形试验中测试STEP-UP与常规治疗的对比 中心.我们的目标是：1）测试STEP-UP的有效性，与常规护理相比，以改善：a）初级 B）在患有先前GDM和/或HDP的妇女中进行精神障碍检测， 先前GDM，和c）在先前GDM和/或HDP的妇女中检测功能障碍和高血压病例。 我们还将：2）研究患者种族、种族和性别对STEP-UP干预效果的异质性， 3）评估STEP-UP组件的覆盖范围、采用、实施、维护和成本。 如果成功的话，STEP-UP可以很容易地传播到全国的社区卫生中心。

ABSTRACT We will test the effectiveness and fidelity of a technology-enabled, ‘stepped care’ strategy to connect high-risk, postpartum patients to primary care within under-resourced community health care settings. Gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) affect up to 8% and 14% of pregnancies annually in the U.S. While GDM and HDP often resolve post-pregnancy, women with these disorders remain at increased, long-term risk of adverse cardiometabolic outcomes. Clinical guidelines therefore recommend that postpartum individuals with prior GDM and/or HDP transition from OB to primary care for ongoing evaluation and/or treatment. Yet studies show only one third of women with GDM and about half of women with HDP see a primary care provider within 6 months postpartum. Of those with GDM, only 1 in 5 complete recommended dysglycemia testing. Limited patient understanding of cardiometabolic risks, poor coordination between OB and primary care, and logistical challenges have been identified as barriers. Women who are Black, Hispanic, and/or low-income, with less education and/or low health literacy, are less likely to receive follow-up care. As early detection and treatment of hypertension and dysglycemia reduces disease progression, complications, and mortality, poor transitions in care is an issue of maternal health equity. In response, we will implement and test our Supporting Transitions to Primary care among Under-resourced, Postpartum women (STEP-UP) strategy. STEP-UP leverages available technologies to support transitions within health centers, from postpartum obstetric to primary care. Specifically, clinical decision support (CDS) in the EHR will prompt provider counseling on the primary care transition; it will also enable providers to order referrals and recommended glycemic tests with a single click. Patients will receive language-concordant materials that reinforce counseling, along with text messages to motivate and remind them to schedule and attend a primary care visit. STEP-UP was designed to be a low cost and ‘low touch’ intervention, yet while a technology-based strategy may work for most patients, it will not work for all. A ‘stepped care’ approach that provides additional, individualized outreach for only those who need it may be necessary. Thus, a centralized outreach coordinator will provide additional, phone-based support for any patient who has not scheduled a primary care visit by 4 months postpartum. We will test STEP-UP vs. usual care in a stepped-wedge trial at 4 large safety-net health centers. Our aims are to: 1) Test the effectiveness of STEP-UP, compared to usual care, to improve: a) primary care visit completion among women with prior GDM and/or HDP, b) testing for dysglycemia among women with prior GDM, and c) detection of dysglycemia and hypertension cases among women with prior GDM and/or HDP. We will also: 2) Investigate the heterogeneity of STEP-UP intervention effects by patients’ race, ethnicity, and language; and 3) Assess the reach, adoption, implementation, maintenance and costs of STEP-UP components. If successful, STEP-UP can be readily disseminated to community health centers nationwide.