Beacon Health System is taking a community-driven approach to improve health for moms and babies. In this conversation, Beacon Health System's Kimberly Green Reeves, vice president of community impact and partnerships, and Cassy White, director of community impact, share how data, care coordination and community involvement are helping reduce infant mortality in Michigan and Indiana. From home visits and remote patient monitoring, to mental health support and community partnerships, learn what it truly means to walk alongside moms and babies from pregnancy through postpartum.

Tom Haederle

Welcome to Advancing Health. In today's episode, learn how Indiana-based Beacon Health System is creating an ecosystem of care to support moms and babies in their community.

Julia Resnick

Hi everyone. I'm Julia Resnick, senior director of Health Outcomes and Care Transformation here at the AHA. This week we observe Maternal Health Awareness Day, and I'm so privileged to be here with two leaders from Beacon Health System in Indiana to talk about their work in this space. I'm joined by Kimberly Green Reeves, vice president of community impact and partnerships, and Cassy White, director of Community Impact.

Julia Resnick

So for those who aren't familiar with Beacon Health System in the area you serve, can you tell us more about your hospital and your community? Kimberly, I'll start with you.

Kimberly Green Reeves

Absolutely. So we are fortunate to be a locally owned health care organization, right now with 11 hospitals across ten counties in two states in the states of Indiana and Michigan. That also includes our Beacon Medical Group offices. And so we have over 35 specialties in health care that we're providing, both urban and a rural perspective.

Kimberly Green Reeves

And what really makes this community unique is again, that we are able to meet people where they are by being locally governed and addressing those needs. And I think also, we have a great community that's surrounded by colleges and universities. One of them being the University of Notre Dame. And so we're working collaboratively with the university there right now, really establishing our partnerships with the University of Western Michigan, as well as the medical school there.

Kimberly Green Reeves

And lastly, we come from a manufacturing community as well. And so, we have the largest RV industry, in our country. And so we're able to work very closely with those organizations and then also with our community support agencies as well, and our not for profits. So it's a really unique perspective that we bring in terms of being able to work collaboratively with those organizations, colleges and universities in order to improve health care outcomes.

Kimberly Green Reeves

But that's really exciting for us in our work.

Julia Resnick

Absolutely. And every time I drive through northwest Indiana, I'm always struck by how many RVs there are. So I love that local flavor. We're really here to talk about maternal health, though. So, can you talk more about the emerging needs or gaps that you're seeing in maternal and infant care in your community? And if there are any populations that you're particularly concerned about or focusing on?

Julia Resnick

Cassy, let's turn to you.

Cassy White

Specifically looking at our Indiana county. So we have three counties that we have hospitals in in the state of Indiana. And part of why we have an emphasis in maternal mortality in our Indiana counties is because the infant mortality rate in those three counties exceeds the state rate. Even more so, we received a grant specifically to focus on eliminating disparities in Saint Joseph County, Indiana, and Elkhart County, Indiana, and a large part of that is because we see a disparity in our infant mortality rates for the black and African-American population.

Cassy White

So in total for the whole county, it's about three times the rate of any other races and ethnicities. And then, we can actually look at it geographically as well. And we have a couple zip codes that have a infant mortality rate ten times higher in those zip codes.

Julia Resnick

Kimberly, anything you want to add?

Kimberly Green Reeves

Actually, I will add something. I will say that we also look at our electronic health record data as well. And what we're seeing in the community, we are also seeing within our health care system as well. So it provided us a wonderful opportunity again to align this work from a strategic perspective as well. So this now is a goal across our health system, which is to address infant and maternal health, which I think is fantastic whenever you need to do anything in the community because it takes all of us.

Kimberly Green Reeves

This is not just something that we can do on our own. It's going to take all of us looking at leveraging some of our resources and our collective assets across our region.

Julia Resnick

All right. So you diagnose the issue. You have the data to show it's a problem. Talk to me about what those strategies are that you're implementing.

Kimberly Green Reeves

So it starts with us internally really looking to see what we need to do differently as a health care system to address the issues and the disparities that Cassie has shared in the previous question there. And so what that takes is us really taking a look at, where we can align our internal resources and where those gaps are.

Kimberly Green Reeves

So for us, it really started with creating or building an infant structure that didn't exist in terms of communicating regarding a patient's needs. The services that we can provide for our families, as well as understanding what other controls were in place to be able to navigate our system. Once we were able to identify that it really is and looking at our community partners to really understand where they plug in.

Kimberly Green Reeves

And so some of this work looks like standing up case management in home visiting internally, but also looking at where are those other services being offered throughout our community. We also focused on clinical supports as a health care system. That is absolutely a place where we need to be. But we understood that we actually needed to hire someone to be able to provide that additional support whose sole focus was on supporting families.

Kimberly Green Reeves

And then that mental health piece is also important. So we're looking at the whole person, if you will, ensuring that we can address any, mental health needs that they may have as well. And then I don't want to lose sight on the educational component. I think that there's a lot to do with education and what we can do to prevent or mitigate risk, but also walk alongside our families throughout their journey ensuring that they have the support that they need.

Kimberly Green Reeves

And then lastly, we also see a really huge value in providing them the necessary resources. And so social drivers of health are important for us. And we're identifying where those exist and how we can be beneficial. And then we like to celebrate our families. And so we're providing them additional resources on different milestones that they hit throughout their OB journey and providing baby essential items in that way that helps keep them encouraged on this journey with us for about 18 months.

Julia Resnick

I love it and love that you're adding joy to that holistic patient care and trying to connect what's happening in the clinic and in the community. Cassy, was there anything else you wanted to add about the work that you're doing?

Cassy White

Kimberly covered it really well. I think I'm actually going to steal some of her words that she has shared before - is that we're trying to create an ecosystem of care. Part of that too, as she mentioned about social drivers of health, we know that 80% of our health is impacted outside of our clinical walls, and that's a large part of what we're trying to address is understanding those basic, basic needs and how we can support and provide resources to meet those needs.

Cassy White

Also, Kimberly's leadership has brought, you know, she mentioned that we're in the RV industry of this country and working on a mobile medical unit to also try to bring the care to our neighbors and community members. So really exciting work in that regard, too.

Julia Resnick

Kimberly, earlier you were talking about walking beside patients on their journey, and trust is such a huge part of that. So how are you all thinking about building trust with your patients and your community members?

Kimberly Green Reeves

So it does start with having conversations to understand, why that trust is diminishing in the first place. We certainly do not want to go into a situation assuming that we have all the answers. In fact, early on in my career, when we had a program focused on trauma informed care support, we went in as a health care system saying this is what we believe you need.

Kimberly Green Reeves

And, we were told, very politely, that we know what's best for us. And so that's just been a lesson that I have carried with me, that instead of doing something to someone, we're going to do it with them. And so very much allowing a process or creating a process, and a safe place for families to come in and be able to provide insight and educate us on the ways that we need to show up for them.

Kimberly Green Reeves

And so part of this work has a consortium component, which is someone coming in with lived experience. And we know that that lived experience can look differently depending on who you are and depending on what you've actually encountered. I often say that we are all matter experts in our own right. It doesn't matter what degrees you have, it doesn't matter what certifications you might have or what education you might have.

Kimberly Green Reeves

We can all lean in on this together. And so that's how we're starting to build trust and rapport with our patients. Also, listening is very important. When someone says that they don't feel right or they've experienced certain elements around their health, to to believe them when you hear that. And so one of the programs that we have is our remote patient monitoring program where we have two RNs working very closely with patients monitoring their blood pressure readings on a regular basis.

Kimberly Green Reeves

I think we get up to three readings during the day. And when they see something that's abnormal or when their patient reaches out to them, they're on the phone with them and finding out, you know, how we can best the system. And sometimes that trust doesn't come on a scheduled plan, right? So what I mean by that is we can't wait until the patient's appointment to be able to be there for that patient.

Kimberly Green Reeves

And so one of our nurses was on her way home and got an alert from a patient that she wasn't feeling well. And so she pulled over to the side of the road to see what she can do to best assist this patient. And she was in a safe space and felt comfortable reaching out to the patient.

Kimberly Green Reeves

And she says, I'm starting to see, stars, you know, and dots. This isn't right. And so the nurse at the time said, why don't you go ahead and get yourself over to the ED at our hospital, and I'll make sure that we have a provider there waiting for you. And we were able to do just that, where the provider was there waiting for this patient in triage to ensure that she received that timely care and could deliver a healthy baby.

Kimberly Green Reeves

And so that's what I mean by making sure that we can walk alongside them in their journey. And that's how we're going to continue to build trust with our patients.

Julia Resnick

Fantastic. And that's a really powerful story. So I know that you all have a fairly new and fairly large grant with Michiana Family Journey. Can you tell me about what that is and what you're hoping to accomplish and what those community partnerships are looking like?

Kimberly Green Reeves

Yes. So this grant, it's a $5.4 million grant through the Office of Health and Human Services. This particular grant is a five-year grant for us. And, one of a kind that allows us to create that ecosystem of care that Kathy referenced earlier. What's most valuable from this is this grant's been around for a very long time, probably 30 plus years.

Kimberly Green Reeves

And so we're coming into this. And while we all approach how we're going to address health disparities differently for families, it is very much a program where you can rely on meeting people that are doing some of the same work and you can leverage some of their best practices. And so that's what this grant is affording us to do.

Kimberly Green Reeves

Much of what you've heard us speak about today, we were able to do kind of in a siloed way, not as coordinated as we're able to do now, but with these additional resources, we are able to ensure that everything is connected, that we are speaking together, that we have a seamless referral process or system in place to be able to deliver the care that we need.

Kimberly Green Reeves

And that additional support around clinical services has also helped us. This particular grant requires a medical provider, that's accessible to the patient, solely dedicated to this patient population. And so we're grateful that we have a family nurse practitioner that can see families all the way prenatally to postpartum and even providing those well-child visits for families as well.

Cassy White

I think even to the partnership piece has been really cool. That's not necessarily a requirement of the grant. It's more so around ensuring we meet our case management numbers and connect people to different resources. But we've taken that to the next level by bringing on community partners that address areas that we don't have the expertise in, such as mental health.

Cassy White

And so we have a partnership, for example, that we've brought them into our system where they can actually, through a HIPAA compliance and data sharing, they're able to log in and see the necessary information that our community health workers are collecting during the onboarding process. And then when a referral is made they're able to be notified and provide that care

Cassy White

right then and there. Kind of creating more of that care coordination across multiple discipline areas, but not that we're trying to do it in-house and saying, let's bring on those other community organizations to address those needs together.

Julia Resnick

I love that. And, you know, collaborating with all of these community partners, especially ones that are in different sectors can be really challenging. So what have you learned from bringing all these people together and trying to create this functional ecosystem?

Kimberly Green Reeves

Just keep going. We're going to hit roadblocks, right? You know, we have our own goals and there are expectations that we have to meet. And so, we have stopped and started and stopped and started again just to ensure that we get this right. We are determined to create this seamless process so that families can go through their OB journey

Kimberly Green Reeves

without feeling the burden of all of the logistical things that it takes in order to have all of these partners at the table. I know no one likes additional meetings, but I think I keep telling the team, we're just getting set up like we have to create this system in order for the system to work in the way that it's supposed to.

Julia Resnick

Any final thoughts? Cassie?

Cassy White

I think it's really cool to see the ownership come into play, with the community health worker team specifically. My background is in epidemiology, and so I always start out with the the team saying I know data collection and data reporting is such a drag, but at the same time, it provides us an opportunity. Because every statistic, every number represents a person and represents a story.

Cassy White

And so help us tell that story because we want that ownership to also be of the people that are a part of our programs, and that they have pride in their story and being a piece of this whole journey.

Julia Resnick

And I think you're both speaking to something really important that, like the operations in the building might not be the most exciting part, but if you're going to create something it needs to have a really strong foundation and I'm really excited to see what you're building and what you're going to continue to build over the years. And for all of you listening on Maternal Health Awareness Day or Maternal Health Awareness Week, we appreciate you.

Julia Resnick

Please join this movement. We have a lot of resources at the edge and maternal and child health, which you can find at www.aha.org. Thank you again to Kimberly and Cassy and looking forward to hearing more in the future.

Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.