There are a multitude of factors that increase risk to parents and babies during the pregnancy and postpartum period, from social factors like housing instability or intimate partner violence to behaviors like substance use and clinical conditions like hypertension or low birth weight.
Maryland has a system in place to flag many of these risks and refer patients to additional support coordinated through local health departments. However, that system has relied on fax transmission of completed referral forms from clinical providers to health departments—creating challenges at all stages of the client support workflow and, ultimately, with data collection.
Recognizing these challenges, the Maryland Department of Health (MDH) is working to digitize the referral forms, and it is capitalizing on that inflection point to improve overall systems for screening, referral, and coordination through a grant from the Health Resources and Services Administration (HRSA).
In March, MDH issued a request for applications (RFA) to support “Integrated Maternal Health Services Coordination.” The Primary Care Coalition (PCC) is thrilled to report we are working with the Department on those efforts between July 2024 and September 2028. Our scope of work includes direct collaboration with providers, hospitals, and patient and caregiver representatives from the District of Columbia’s Maryland suburbs, the Eastern Shore, and the Baltimore region to align healthcare processes with opportunities for supportive intervention and data collection. The work is designed to ensure a consistent flow of information so patients in need of support can receive it. Ultimately, it will also help the state to understand how well those referrals help to address what the RFA called “significant racial and regional disparities in maternal mortality rates (MMR) that fall more heavily on non-Hispanic Black birthing people” as well as those in the service areas.
“This project provides a unique opportunity to work with patients, providers, and clinical partners to impact how a patient’s physical, mental, and social needs are assessed at pivotal touch points during pregnancy and birth,” said Nexus Montgomery Senior Program Manager Grace Townsend. “We are committed to finding innovative ways to streamline and improve the care coordination process, which ultimately impacts the health and well-being of at-risk pregnant and postpartum parents across the state of Maryland.”
Maryland has a system in place to flag many of these risks and refer patients to additional support coordinated through local health departments. However, that system has relied on fax transmission of completed referral forms from clinical providers to health departments—creating challenges at all stages of the client support workflow and, ultimately, with data collection.
Recognizing these challenges, the Maryland Department of Health (MDH) is working to digitize the referral forms, and it is capitalizing on that inflection point to improve overall systems for screening, referral, and coordination through a grant from the Health Resources and Services Administration (HRSA).
In March, MDH issued a request for applications (RFA) to support “Integrated Maternal Health Services Coordination.” The Primary Care Coalition (PCC) is thrilled to report we are working with the Department on those efforts between July 2024 and September 2028. Our scope of work includes direct collaboration with providers, hospitals, and patient and caregiver representatives from the District of Columbia’s Maryland suburbs, the Eastern Shore, and the Baltimore region to align healthcare processes with opportunities for supportive intervention and data collection. The work is designed to ensure a consistent flow of information so patients in need of support can receive it. Ultimately, it will also help the state to understand how well those referrals help to address what the RFA called “significant racial and regional disparities in maternal mortality rates (MMR) that fall more heavily on non-Hispanic Black birthing people” as well as those in the service areas.
“This project provides a unique opportunity to work with patients, providers, and clinical partners to impact how a patient’s physical, mental, and social needs are assessed at pivotal touch points during pregnancy and birth,” said Nexus Montgomery Senior Program Manager Grace Townsend. “We are committed to finding innovative ways to streamline and improve the care coordination process, which ultimately impacts the health and well-being of at-risk pregnant and postpartum parents across the state of Maryland.”
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