Heart Safe Motherhood

An evidence-based program for postpartum women with hypertension

Opportunity

Preeclampsia is a pregnancy disorder characterized by high blood pressure (hypertension) and increased urine protein levels. Blood pressure in patients with pregnancy-related hypertension can take as long as three months to normalize and is likely to spike in the first ten days after delivery, putting new moms at risk for stroke, seizures, and organ failure. 

In 2013, the American College of Obstetricians and Gynecologists (ACOG) issued guidelines to monitor postpartum blood pressure for this population at two points - once at 72 hours and again seven to 10 days after delivery. When ACOG released their recommendations, there was no guidance or best practice model for achieving the new standards.

When we started this work, the standard of care at the Hospital of the University of Pennsylvania (HUP) required new moms to return to the office to have their blood pressure taken at the designated touchpoints. Newly postpartum women often encounter barriers for in-person postpartum visit attendance. Show rates at these visits were less than 50 percent in the two years after the recommendation was made. Racial disparities in care also existed, with non-Black women almost twice as likely to attend this visit.  

Hypertension was the leading cause of seven-day readmissions for obstetrics patients at HUP. Despite numerous efforts to improve show rates - including increasing the availability of appointments and issuing phone and text reminders, practices were not meeting ACOG guidelines.

Intervention 

Heart Safe Motherhood (HSM) is a first-of-its-kind text-based program for postpartum blood pressure monitoring. HSM enables patients to track their blood pressure from the comfort of their home and communicate with their care team without visiting a doctor’s office. Only patients with concerning blood pressures or symptoms may be asked to come in for an appointment.

The process works as follows:

  • Inpatient physicians and nurse practitioners on labor and delivery and postpartum service identify and enroll at-risk women based on a set of eligibility criteria using diagnoses and vital signs.
  • Participants are given a digital blood pressure monitor for at-home use. Training on how to use the monitor and education about the program occur prior to discharge.
  • Upon discharge, an automated blood pressure monitoring protocol powered by Way to Health is enacted. Patients are prompted by twice-daily text messages to capture and share their blood pressure for ten days.
  • Patients receive automated, real-time feedback to self-reported blood pressure readings based on a provider-determined algorithm.
  • When blood pressures are high enough to necessitate intervention, the platform pushes real-time alerts to providers.
  • Providers reach out for more information, start or adjust medication, or triage patients to in-person care, depending on the circumstances.

Through automation and exception handling, HSM makes it possible for one provider to manage the blood pressures of an entire hospital’s worth of enrolled deliveries in just a few hours a week.

Impact

HSM drives better maternal outcomes, improves patient experience, and reduces the total cost of care for women with pregnancy-related and chronic hypertension in the immediate postpartum period. 

In 2017, we completed a randomized controlled trial comparing HSM to the usual care of one-time, office-based in-person blood pressure checks in the days after delivery discharge. We found an increase in our ability to obtain at least one blood pressure within ten days after discharge, with 92 percent of patients texting a blood pressure compared to 44 percent of patients attending their office visit. We met ACOG guidelines for blood pressure ascertainment at the two recommended time points in 80 percent of patients using HSM. Approximately 15 to 20 percent of women had elevated blood pressure requiring medication initiation or adjustment. There were no readmissions among HSM participants, and women enrolled in the program were more likely to attend their postpartum visit, a valuable touchpoint to evaluate physical and mental well-being after delivery and support contraception planning and breastfeeding. At scale, postpartum hypertension readmission rates at HUP dropped from 5 percent before HSM to 1 percent, and hypertension is no longer the leading cause of seven-day obstetrical readmissions.

A secondary analysis of the trial found that HSM eliminated the observed racial disparities in postpartum hypertension blood pressure ascertainment. Before the intervention, non-Black women were significantly more likely to attend an in-person blood pressure check than Black women, yet Black women were at higher risk of poor outcomes. With HSM, we were able to increase our ability to capture blood pressure for all patients while eliminating the previously observed racial disparities.

HSM is the standard of care for obstetrics patients at HUP, Pennsylvania Hospital, and Princeton Medical Center. Improved blood pressure ascertainment and reduction in hypertension-related readmissions have been observed at all three hospitals.

COVID-19

In response to COVID-19, we are supporting additional care teams to implement HSM to reduce the amount of time patients spend in the hospital and minimize follow-up visits in the early postpartum period. Knowing that patients can safely monitor their blood pressure at home has allowed for earlier discharge after delivery.

Phase 4: How others work
Collaborators

Sindhu Srinivas, MD, MSCE
Adi Hirshberg, MD

Innovation leads

Katy Mahraj, MSI
Matt Van Der Tuyn, MA
Abbie Lund, MA
Emily Seltzer, MPH
Roy Rosin, MBA

Platforms
Funding
Innovation Accelerator Program
Penn Presbyterian Harrison Fund Award
The Preeclampsia Foundation
Awards

National Innovation Challenge, American Hospital Association, 2018
Philadelphia Heart Science Forum Innovation Challenge, American Heart Association, 2016
National Improvement Challenge, Council on Patient Safety in Women's Health Care, 2016
Clinical Innovation Award, Vizient, 2018
Healthcare Innovator Award, Philadelphia Business Journal, 2018

Innovation Methods

A day in the life

One of the best ways to learn more about a problem area is to experience it yourself. Immerse yourself in the physical environment of your user.

Do the things they are required to do to gain a firsthand experience of the challenges they face. Completing a day in the life exercise will enable you to uncover actionable insights and build empathy for the people you're hoping to help.

A day in the life

We conducted several hours of contextual inquiry in waiting rooms and other clinical spaces frequented by our target population.

A common theme across observations was that pregnant patients were using their cell phones to communicate via text message. This “aha!” moment led to the team’s decision to test a text-based intervention to capture blood pressure data.

If pregnant women prefer this modality of communication and postpartum women struggle to come to in-person visits after delivery for a variety of reasons, why not explore if text messaging could help fix the issue?

Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
 
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
 
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
 
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end
In the first iteration of HSM, enrolled patients received text messages from a physician acting as an automated bot.
 
Piloting HSM as a fake back end allowed us to test various approaches to patient engagement, including sending personalized messages with the patient and baby's names, pushing reminders at different times, and contacting a support person if the participant did not respond to a morning message.
 
It also helped us gain buy-in from stakeholders to move forward with the development of the intervention as we were able to validate that patients could be monitored safely at home.

Commentary

Co-creation with patients

While our aha moment occurred when we noticed how frequently pregnant patients were on the cell phones text messaging in waiting rooms, it was essential to include patients in the program's development. At the end of each pilot iteration, we interviewed participants to learn about what worked, what didn't and collect ideas for improving the program. Small adjustments along the way resulted in a successful final product.

Adi Hirshberg, MD

Keep things simple

It was important to us and our patient population to use simple technology. We purposefully chose non-Bluetooth technology, given the limited wireless access many of our patients have. Using simple technology allowed us to provide care to more patients through the program. Our patients informed us that texting in the blood pressure reading from their cuff was not an obstacle to their participation.

Adi Hirshberg, MD

Videos

Pitch Day 2018

Stories of Innovation - Heart Safe Motherhood

Press