This post is part six in a 10-part series on care model innovation.
Humans of New York (HONY) is a blog and Facebook page that features portraits of New Yorkers, each paired with a caption in the subject’s own words. With over 11 million followers, HONY is adept at bringing into focus the experiences that shape people’s lives. A recent post made me stop in my tracks and think. The subject said:
My children’s father was physically and emotionally abusive, so by the time I left him I had very low self-confidence. I needed something to boost my ego. One day I saw some firefighters handing out recruitment material on the street so I decided to give it a try. All the female recruits trained together, because we had to work harder than the men to pass the test. We trained for six months, three hours a day. I’d go straight from my job to the training sessions. I’d bring my kids with me, and when it was my turn to do the drills, the other women would take turns passing them around. At the end of the six months, I was 120 pounds of solid mass, and I passed the test easily. I never became a firefighter, but those women are still my friends.
I love a lot of things about this story. I love her determination and resourcefulness and resilience. And I love how other women gave her a boost. Their practical and emotional support helped her get fit and gain the confidence she needed to turn her life around. Really, it was in large part because of these other women that she was able to access the determination, resourcefulness, and resilience inside herself.
As someone who has been studying health creation, it also struck me how much health was created in this story, without a single health care professional or facility taking any part. She’s fit. She found a sustainable path out of an abusive relationship. She has lifelong friends. Is there any clinical intervention that could replicate this kind of impact on a person’s wellbeing?
I’ve been stewing a lot on the powerful health-creating effects of friends and peers since I spoke to Susannah Fox last month. I’ve known Susannah since 2009, when I read a seminal white paper on e-Patients that she helped write, and connected with her through Twitter. Her work has continued to inspire me since then, and we have stayed connected thanks to social media. I reached out when I learned that she has decided to devote herself full-time to promulgating a vision of peer-to-peer healthcare. She is writing a book on the topic, advising companies and organizations looking to innovate in this space, and taking up the role of Entrepreneur in Residence at the Robert Wood Johnson Foundation.
In a letter announcing her departure from the Pew Research Center to pursue this calling full-time, Susannah wrote,
For me the new truth is that the most exciting development of the connected health era is not access to information, but access to each other…The power of community in health can revolutionize the way care is experienced and delivered. It is our job as an industry to bring that to life, to legitimize and formalize the very real and quantifiable role that community plays in our health.
When Susannah and I spoke, we talked about CenteringPregnancy, a group visit model for prenatal care. It is one of my favorite examples of the powerful role of community in health. And it is a particularly effective one. Controlled trials show that the Centering model reduces preterm birth, low birth weight, and cesarean delivery and improves breastfeeding rates, prenatal knowledge, and satisfaction.
There are many variants of group-based prenatal care, but CenteringPregnancy is the leading model, with standard processes and content and a national organization, the Centering Healthcare Institute (CHI), that provides training and implementation support. It is through these standards and training that CHI has “legitimized and formalized” peer-to-peer healthcare.
Facilitating Engagement and Connection
CHI’s model emphasizes the participatory potential of group visits. Women actively engage in self-care (for example, taking their own blood pressure and recording it in their own health records), and the midwives and doctors who lead the groups are trained to be facilitative. Instead of lecturing or counseling, clinicians try to get out of the way and unleash the potential of women to empower and educate each other. They offer their clinical perspective to supplement and contextualize the wisdom of the group. Most of the “care” in this prenatal care model comes from other women.
This peer-intensive approach appears to directly improve health and reduce costs. Researchers have found that the more the women guide the discussion and connect directly with each other, the lower their chances of giving birth preterm. Essentially, connectedness has a dose-response effect.
Preventing Preterm Birth
The effect on preterm birth is not just statistically significant. It is profoundly clinically significant. Despite the prevalence of preterm birth and its devastating impact, there are very few effective clinical prevention strategies. The only medical strategy that works – giving progestin – works only in a small subset of women: those who have already had a preterm birth and those with a diagnosis of “short cervix” based on transvaginal ultrasound.
Health plans and Medicaid programs, in an attempt to rein in the runaway costs of preterm birth and its consequences, have prioritized identifying women who can benefit from progestin therapy and managing their care so they adhere to treatment. As a result, there is a massive quality improvement enterprise around risk screening and progestin treatment in pregnancy.
Meanwhile, the cost to start up and sustain a CenteringPregnancy program pales in comparison to the amount invested in these medical efforts. Given the apparent enthusiasm for averting preterm births, a rational person would expect to see CenteringPregnancy in every community, but it is still far from a routine offering. Only 3% of new moms report receiving most or all of their prenatal care in a group setting, according to the national Listening to Mothers Survey.
Care Models That Really Work
This is the fourth care model I have looked at in my Care Models That Work series after midwife-led care, community-based doulas, and Nurse-Family Partnership. I am more convinced than ever that we have both an opportunity and an imperative to radically redesign maternity care, and that the “health creating” lens offers so much more hope than if we begin from the premise that pregnancy is an emergency waiting to happen. All of these care models offer meaningful and long-lasting benefits for people’s health and their lives. And none of them introduces any detectable harm when implemented properly. They also all reduce disparities. Amazingly, society does not face a higher price tag for these benefits. In fact, there are clear and substantial savings to be realized. In my mind, there is nothing not to love about these care models, and no reason to delay increasing access to them.
It is clear to me that how we pay for care is the main force holding these models back and maintaining the status quo of unconscionably poor outcomes for women and babies. So I will devote the second half of this project to figuring out how to use payment innovation to scale up these models, and their impact.