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

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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.