Improving Birth Outcomes for Black Families through Community-Clinic Collaborations
ConnectRx Wisconsin has emerged as a revolutionary solution to reducing health and social needs risks of Black pregnant women and birthing persons served through local hospitals and clinics. Through a wrap-around service delivery model designed by initiative partners with community input from more than 300 Black community members, ConnectRx Wisconsin deploys a dual workforce of clinic- and community-based health workers and trained doulas to support patients’ health, social, economic, mental health and other resource needs.
– source: UW Health press release April 16, 2024
At a Glance
This project, led by the Dane County Health Council and the Foundation for Black Women’s Wellness, aims to reduce racial inequities in birth outcomes through care coordination. Wisconsin has the highest Black infant mortality rate in the country, and Black infants born in Dane County are two times more likely to die in their first year of life than white infants. Factors contributing to racial disparities in birth outcomes are attributable to social and economic challenges in Dane County, including inadequate housing, food insecurity, lower educational attainment, fewer economic opportunities, poverty and structural racism. The project has made significant progress toward its goals in the first three years. ConnectRx is a closed-loop referral system developed in partnership with Epic Systems and UW Health and launched in April 2022. ConnectRx allows providers to make social prescriptions and integrates over 1,200 unique resources into patients’ electronic health records. Six Black female community health workers were hired to enhance maternal care teams, and a partnership with the Foundation for Black Women’s Wellness provided doula support. These efforts have resulted in assistance for over 200 Black birthing persons and their families, addressing needs such as rental assistance, homelessness prevention, mental health support, job-related assistance and food pantry referrals.
The Challenge
While Dane County is often cited as one of the nation’s best places to live and is home to some of the best health care institutions in the country, Black women and children in the community face inequities in health, educational and economic outcomes. Wisconsin has the highest Black infant mortality rate in the country, and Black infants born in Dane County are two times more likely to die in their first year of life than white infants. Factors contributing to racial disparities in birth outcomes are attributable to social and economic challenges in Dane County, including inadequate housing, food insecurity, lower educational attainment, fewer economic opportunities, poverty and structural racism. Black women face these challenges from infancy through adulthood, creating a cycle of chronic stress that accumulates and negatively affects their children.
Project Goals
This project, led by the Dane County Health Council and the Foundation for Black Women’s Wellness, aims to reduce racial inequities in birth outcomes through care coordination. The goals for this project are to:
- Create a centralized referral system that identifies and responds to Black families’ health and social needs by connecting them with nonprofits that provide services related to those needs.
- Train a new corps of community health workers and doulas to partner with health system care teams on Black families’ needs.
- Build bidirectional clinical-community referrals and community-wide coordination of resources.
Progress Update
Significant progress was made in the first three years of the project. In the first year, partnerships between Epic Systems and UW Health were secured to develop a closed loop referral system, called ConnectRx, to efficiently refer patients to other organizations for care coordination. The Epic system was merged with United Way’s 211 community resource directory allowing providers to make social prescriptions for their patients. By April 2022, ConnectRx was fully implemented and intertwined with clinical and community-based patient support services infrastructure. On the health care side, the process begins with a Universal Patient Risk Screener, and as of December 31, 2022, over three thousand patients have been screened across Dane County. Because United Way’s 211 resource directory was imported into all partner organization’s Epic systems, over 1,200 unique resources were provided directly to the patients’ electronic health records.
Six Black female community health workers (CHWs) were hired to enhance maternal care teams and increase workforce diversity. The project also partnered with the Foundation for Black Women’s Wellness (FFBWW) to provide doula support to clients. The first doula referral was placed in May 2022, and of the Black women and birthing persons referred for doula services, 84 percent had a total household income of less than $25,000, 98 percent rent their housing, 30 percent reported being homeless, 78 percent had a high school degree or less, 82 were single heads of household and 60 percent were covered by Medicaid or medical assistance.
Since ConnectRx’s launch, CHWs and doulas have supported over 200 Black birthing persons and their families by providing one-on-one resource coordination support to address unmet social determinants of health needs. More specifically, the CHWs and FFBWW doulas have:
- Supported 60 Black birthing families that resulted in a healthy birth.
- Helped over 50 families obtain rental assistance and 20 families end their homelessness.
- Provided over 100 families with diapers and wipes and over 35 families with pack and plays to support safe sleeping habits.
- Connected clients to 82 mental health supporting resources.
- Helped clients obtain proper attire for job interviews and connected clients to employment resources to help with resume writing and interviewing skills.
- Sent over 218 referrals for food pantry services and delivered food to over 100 families’ doorsteps.
The project has also made notable achievements in community engagement. In the project’s first year, the Dane County Black Maternal Child Health Alliance (BMCHA) was established comprising 21 members including local Black women leaders, advocates and community influencers. Members of the BMCHA also sit on the Dane County Health Council to ensure community-informed work that responds to the needs of the communities most directly impacted by ConnectRx. BMCHA hosted the Black Maternal Child Health Summit during the second year of its membership which featured nationally recognized birth justice leaders including Monica R. McLemore, local birth workers and mothers personally impacted by the loss of a baby. While the majority of participants were from Wisconsin, the summit attracted almost 200 attendees representing 27 states, two Canadian provinces and 128 unique zip codes.