The Medicaid Innovation Collaborative (MIC) – a partnership between Peoria-based OSF HealthCare and four Federally Qualified Health Centers (FQHCs), celebrated its one-year anniversary by highlighting a long list of milestones achieved. MIC provides a variety of digital care services and personalized support for Illinois Medicaid patients through programs developed by OSF OnCall.

The state-funded, five-year initiative is designed to transform health care delivery to improve outcomes, decrease disparities and reduce costs using sustainable programs.

The FQHC partners in the program include Heartland Health Services (Peoria, Illinois), Chestnut Health Systems, Inc. (Bloomington, Illinois), Eagle View Community Health System, Inc. (Oquawka, Illinois), and Aunt Martha’s Health & Wellness (Danville, Illinois).

To date, MIC has been able to stand up several programs to expand services by:

• Providing pregnancy and postpartum support 24/7 to enrolled patients; featured on this Health Accelerated podcast.
• Offering remote patient monitoring for chronic disease management including asthma, diabetes hypertension, COPD and heart failure.
• In a collaboration with Illinois Central College, training OSF digitally-enabled health navigators to be embedded within communities across the state and FQHC community health workers; within their facilities and co-located in community-based organizations, including homeless shelters. 
• Expanding breast cancer screenings through digital outreach, making it easy for patients to schedule this important test
• Extending health and wellness education with the goal of reducing chronic disease risks associated with diet and nutrition, exercise, unhealthy weight and smoking
• Launching culturally sensitive, easy-to-use communication tools.
• Developing a systematic approach to assessing social determinants of health and tracking data to prioritize patient outreach, optimize workflow and to identify which patients might fit into specific programs. Future work will integrate all information with a patient’s electronic record for providers to have a holistic view of their patients.

Jennifer Junis, senior vice president for OSF OnCall who also chairs the MIC Governance Council, says community health workers embedded in vulnerable communities also screen individuals for social service needs and they’re connected with local resources to provide support for food, transportation, child care and affordable housing, among other factors that contribute to improved health and wellness.

During a day-long session earlier this week, FQHC leaders and frontline employees reviewed progress toward goals outlined for the first year.

Chestnut Health Systems in Bloomington:

•  Began work on a building renovation and hiring for a new dental clinic that will serve Medicaid participants. 
•  Collaborated with a local homelessness service provider/food pantry to organize and implement a Food Pharmacy. Providers at Chestnut screen patients for eligibility criteria and prescribe use of the food pharmacy services. The pharmacy provides fresh and healthy food options often worth hundreds of dollars.
• The CHW program has solidified co-locations for staff at six partnering agencies.

Heartland Health Services in Peoria:

• Built a new team within HHS and the framework to support digital care programs and to provide virtual primary care in homeless shelters.
• Began building trust with leaders and residents of homeless shelters through food and clothing drives and providing COVID-19 rapid kits.
• Hired a digital support manager and community health navigators who have also been trained on tele-diagnostic equipment that can be used to support virtual visits.
   

Aunt Martha's Health and Wellness in Danville: 

•  Trained and hired community health workers.
•  Established monthly Healthy Behavior meetings at the YMCA and Public Library.
•  Educated more than 100 people in the community about resources and how to take control of their health.
•  Expanded training for CHWs on cultural diversity, domestic violence and sexual assault.

Eagle View Community Health System in Oquawka:

• Deployed CHWs who are providing services in three locations in the community.
• Implemented a new electronic health record system (Epic) that allows for better data collection and reporting on health outcomes.
• Hired a new transportation van and hired a transportation director.

Junis says these efforts are designed to wrap a 24/7 digital safety net around patients that is available 365 days a year

“So if you have a question in the middle of the night, you don't have to go to an emergency department, or you don't know who to call. You can reach out to us and it's through text messaging or calls and we're available. So that's really the transformation piece. Is that we're not episodic but we're really meeting patients where they are and where they need us the most, at the times that they need us.”

The effort is expected to lower health care costs by keeping people out of the emergency department or the hospital, the most costly point of care. Savings can also be created by scaling the effort with telehealth providers overseeing care for many patients at a time.

MIC will continue into year two with goals of improving dental care for patients, providing virtual health to residents of homeless shelters, and enrolling new patients in existing MIC programs. Junis says it’s also about improving based on feedback.

“Year two is about optimization, and coordination and collaboration, and really continuing to work together to understand all of our different components of the holistic care of a patient and how we all play such a big role in that.”

Video Clips with Jennifer Junis, Senior Vice President for OSF OnCall Digital Health

Samantha, a 25-year-old woman who recently had her second baby, enrolled in a new program through OSF OnCall Connect that provides support to pregnant women with Medicaid insurance.

The program likely saved her life. Eight days after she delivered a healthy baby girl, Samantha messaged her care team through an application that can be accessed on a tablet or smartphone that serves as a key connection and education tool.

It’s available through the OSF OnCall Connect pregnancy-postpartum program and connects patients instantly to a nurse. Samantha explained she was suffering from a terrible migraine headache and chest pains. The OSF OnCall nurse immediately recognized the significance of her symptoms and notified the advance practice provider who recommended Samantha go directly to the Emergency Department. She had a serious condition called postpartum pre-eclampsia, which can lead to brain damage, stroke and death if left untreated. Samantha was to make a full recovery. She’s also is a Black woman, and in the United States, pregnant Black women are three times more likely than white women to die as a result of pregnancy.

A report from the Centers for Disease Control and Prevention (CDC) found 80% of maternal deaths between 2017 and 2019 were due to preventable causes, and many of the deaths occurred within the first year after giving birth. The statistics are behind the new OSF program that was launched under the umbrella of a state-funded program called the Medicaid Innovation Collaborative.

Kate Johnson, clinical supervisor for Digital Care at OSF, says 970 women with Medicaid insurance have signed up for the pregnancy and postpartum program since it was launched in August. Currently, nearly 500 women are actively enrolled. Johnson says pregnant women, especially those who have a lack of resources, are eager to have the 24/7 connection offered through an app they can download on their smart phone or tablet

“It provides check-in questions, routine questions, like ‘Are they having any signs of infection, UTI symptoms? Are they struggling with breastfeeding; having any depression symptoms?’ And if they answer in any kind of an alarming way, that lets our nurses know right away … sends them an alert, and we're able to contact those patients via telephone and triage if we need to.”

Women on Medicaid can self-enroll in the free program starting eight weeks into their pregnancy by going online to register. After they enroll, women will be sent a blood pressure cuff to take regular readings and the program can connect them to other equipment they might need such as a breast pump.

Women can also enroll in the postpartum program without having participated in the pregnancy support. Johnson says women will receive new education messages each week throughout their pregnancy and postpartum.

“I think the education that we provide those moms during their pregnancy is awesome because it's getting them ready to deliver their baby. So, helping them think about things like how they want to feed their baby, birth plan, pain management for their delivery, things of that nature.”

Connecting women to mental health support

The CDC study found mental health issues were among the preventable, pregnancy-related conditions that lead to higher mortality rates. Johnson says that’s why the program offers depression screening upon enrollment in the pregnancy program, and when they deliver, they have the option to enroll in the postpartum portion. For postpartum support, they can indicate the type of support they need, such as selecting whether they delivered vaginally or via C-section or if they require information on infant care.

Even though women are screened for depression in the hospital after they give birth, it’s often six weeks before they have a follow-up appointment. Johnson says that’s sometimes too late, and women too often suffer in silence.

“So, we will be screening her right upon enrollment into the postpartum loop. And then we'll do a two-or three-week check-in to make sure emotions are doing okay. There is such a huge change in emotions postpartum with the changes in your hormones and bringing a baby home plus the sleep deprivation. So, we want to be there to support them in that initial six weeks before they see their provider.”

A patient named Jane enrolled and indicated she suffered from untreated postpartum depression after her first child, which is a risk factor she could experience that with another pregnancy. Jane had messaged regularly after delivering her second child, and by her third week, made contact and told the OSF OnCall nurse she had worsening depression to the point she had suicidal and homicidal thoughts. The woman was taken to a local hospital to get help, and remained calm while waiting for the ambulance because of the connection and trust she felt with a nurse she had had regular contact with through the program.

The OSF OnCall Connect pregnancy and postpartum initiative also screens for social determinants of health – all those factors outside of a medical office, such as food insecurity, financial struggles, housing and transportation challenges, to fill the gaps that could contribute to the woman’s health and the health of their baby. Johnson shares there are common struggles.

“I think what we're seeing mostly is patients who are struggling with transportation to get to their actual OB provider appointments, so we are able to align transportation for them in most cases. Just this past weekend, we had a patient that had no car but needed a prescription. So, we aligned her with a pharmacy that delivered those medications directly to her door.”

Women with Medicaid insurance enrolled in the program have the option of being connected with a digitally-enabled community health worker who can help them navigate ongoing support from community-based organizations. Translation services are part of the support provided to make sure women get the medical care and outside resources that can help meet their social service needs met.

Video clips with Kate Johnson, clinical supervisor of Digital Care, OSF OnCall Connect