The high rates of maternal mortality and morbidity in the U.S. are unacceptable, so leaders at The Southeast Permanente Medical Group decided to do something about it and created the “cocoon pregnancy care model.” This innovative approach at Kaiser Permanente Georgia, where The Southeast Permanente Medical Group delivers care, puts the patient in the center of protective layers of care to optimize health, enhance the care experience and achieve the best possible outcomes.
The need for such an intervention is clear. The U.S. has the highest rate of maternal mortality of any developed country and it’s getting worse, which is why the AMA is advocating to improve maternal health. The rate climbed to 23.8 maternal deaths per 100,000 live births in 2020, up from 17.4 in 2018, according to the Centers for Disease Control and Prevention (CDC). The maternal mortality rate for Georgia between 2018 and 2020 was 28.8, the CDC says.
CDC data also shows that Black and Indigenous women are three to four times more likely to die from pregnancy-related causes than white women.
The Southeast Permanente Medical Group, which is a member of the AMA Health System Program, provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Kaiser Permanente Georgia delivers about 2,500 babies a year in its 32-county service area that includes the Atlanta metro area and Northeast Georgia. And leaders there designed a perinatal patient-safety program that addresses three factors that affect maternal morbidity and mortality:
- Socioeconomic status.
- The ability to access care.
- The quality of care received.
The planning, implementation and early results of the program are detailed in a case study, “A Cocoon Pregnancy Care Model to Reduce Maternal Morbidity and Mortality.”
The Southeast Permanente Medical Group team examined data that showed 21.1% of their obstetric patients had chronic hypertension or pregnancy-associated hypertension. The rate was 54.6% for Black obstetric patients, 24.4% for white patients, 3.2% for Asian patients, and 2.5% for Hispanic patients.
The initiative works upstream to optimize the health of reproductive-age women before pregnancy by ensuring that those with diabetes, hypertension or other chronic health conditions are on medication to manage them. Contraceptives were made available to those who didn’t desire pregnancy. Those who desired pregnancy were referred to maternal-fetal medicine physicians who counseled them on managing their diabetes and hypertension.
The care model blends telehealth and remote-monitoring innovations with traditional elements such as counseling.
Virtual visits provide more frequent touch points, which helps keep blood-glucose levels or blood pressure under control. The remote monitoring was programmed to send alerts to physicians via the integrated EHR if levels put patients at risk.
There were 736 obstetric patients enrolled in the cocoon pregnancy care model in 2019, and 638 severe-range alerts were sent. Labor was induced 36 times to avert the potential for poor outcomes, according to an article on the Permanente Medicine website.
(The case study notes that publication of a matched retrospective cohort study evaluating outcomes of the remote patient-monitoring hypertension program is in progress. It shows “better-controlled BPs, better linkages to hypertension care postpartum, and a trend toward improved perinatal outcomes.”)
Twenty weeks into the pregnancy, patients were given a number to call to get answers from specially trained maternal-child health nurses.
These “nurses were a crucial part of the member’s support provided through their weekly appointments, educational support, and outreach,” the case study says. “They provided a listening ear, encouragement for the mother, and a clear sign that the care team cared deeply about their well-being and pregnancy outcomes.”
Ob-gyn Ericka C. Gibson, MD, MPH, is a co-author of the case study report and The Southeast Permanente Medical Group’s perinatal safety and quality physician program director.
Dr. Gibson recently spoke with the AMA about the cocoon pregnancy care model and its beginnings with KP Connected Pregnancy Care.
AMA: How did the COVID-19 pandemic affect the development of the care model?
Dr. Gibson: There were definitely discussions about beefing up virtual care options for patients prior to the pandemic. KP Connected Pregnancy Care was in development prior to the pandemic. At the start of the pandemic, we had to pivot quickly to be able to offer prenatal care in a virtual space.
The response from both patients and physicians was overwhelmingly positive. The patients liked having the virtual care options. They didn't feel like they were receiving care that was lower quality than an in-person visit.
Likewise, physicians felt it was an effective and safe way of delivering care. KP Connected Pregnancy Care came from the prior motive of wanting to ramp up virtual care offerings, and the pandemic forced a quick pivot to develop this program and care pathway.
AMA: Please describe the “cocoon” wrapped around the patient.
Dr. Gibson: The idea for the cocoon comes from one, placing the patient—our pregnant person and baby—at the center of everything we did in all of our initiatives, our programs, our aims, and then, two, by providing multiple layers of protection, that would really optimize outcomes for both.
We thought about the people involved in the health care team—traditionally, we think of the obstetrician, nurses, maybe a midwife if they're involved in the care model.
But then we thought about what other supports would help to optimize outcomes. That's the involvement of specialists for some of our patients with high-risk medical conditions—our maternal-fetal medicine consultants, other physicians that may be involved in the patient's care, maternal-child health nurses, and lactation specialists.
When we think about health, there's obviously the physical component. But the pandemic is really highlighting the mental and social determinants of health, such as incorporating a perinatal behavioral health clinician and incorporating care coordinators and social workers to address those social determinants of health needs. As we thought about those components, the care team—the “cocoon”—continued to grow from that.
AMA: What kind of feedback have you received? What are patients telling you?
Dr. Gibson: The response has been very positive. Being able to link a patient with depression or anxiety or a prior poor outcome with a behavioral health clinician that's specifically trained for the obstetric population—patients like having resources like that.
It’s helpful to link a patient with a social worker if they are having issues with transportation or affording medications versus directing them to the community or online to try to find those resources themselves—the patients really appreciate having these additional supports.
We also surveyed patients who’d gone through the remote-monitoring programs compared to patients who weren’t in involved, and they felt more satisfied with their prenatal care. They felt that they were informed about their healthcare and felt more supported.
Early in the process, we heard from patients that the program has definitely helped them navigate some of the challenges of making it for in-office, face-to-face visits.
AMA: How does this program fit into the overall effort to lower maternal mortality?
Dr. Gibson: There’s more patient involvement and education about pregnancy and symptoms of concern. If you look at other programs—like the involvement of doulas or group prenatal care—some of the positive outcomes that are seen with those care models implies that the education of patients and their hands-on involvement in their own care was part of why those things may be successful in improving outcomes.
The other element to our program is health equity, such as creating access for some patients who may not otherwise come into the office for prenatal visits. If distance, a job or childcare is a barrier to making prenatal appointments, this provides an alternative way of staying connected with their prenatal care.
I think using remote technology has helped us to obtain earlier detection of the biggest contributors to maternal mortality, which is hypertensive disorders of pregnancy. We can use the technology to educate patients on hypertensive disorders of pregnancy, and then have patients play a role in home-based monitoring and earlier intervention.