Table 3.

Recommended Strategic Steps, in Detail

Agenda Planks	Strategic Steps
I. Eliminate disrespect and bias in health care	Create a regional or national board of experts in health equity to promote best practices, assess and approve the quality of curricula, develop and disseminate measures of accountability for continued progress by individuals and institutions in the elimination of racism and bias in clinical practice, and oversee evaluation of the impact of such curricula on practices; Engage patients in the design and implementation of the curriculum; Embed the curriculum longitudinally in the initial training of all health care workers and licensing of clinical providers; Address directly the historic/structural roots of racism in institutional policies and clinical practice, and encourage the American College of Obstetrics and Gynecology to establish administration of the Jackson-Hogue stress scale to Black women as a standard of practice (Jackson, Hogue, & Phillips, 2005); Incorporate innovative methods/best practices to strengthen empathy, knowledge, and understanding (drawing from narrative medicine, theater, film, and the visual arts); and Fund evaluation of education programs to establish impact on clinicians’ behaviors over time and tie the results to accreditation of training programs.
II. Invest in communities: Build technical capacity of CBOs dedicated to the health of BIWOC over the life course	Create a tax break to incentivize public/private funders to allocate 2% of annual expenditures for CBO capacity building and infrastructure building; and Fund a technical support center to collect and disseminate resources for: Governance and board development; Financial management and operations and 501(c)(3) process; Donor relations, fundraising, grant writing, and strategic partnering for innovative grantmaking; Program development, budgeting, and monitoring and evaluation; Communication to increase visibility and funding; Community engagement skills and advocacy strategies for policy change; Identification of local legal and business resources for pro bono services; and Acquisition of paid seats at the table of local public.
III. Transform and extend the model of care for the postpartum year: 1. Develop team-based approaches	Create multidisciplinary teams composed of clinicians (physicians, advanced practice nurses, midwives, social workers, mental health therapists) and CHWs (doulas, and/or peer navigators); Equip nurse-midwives and extend the nurse-midwifery model to care for women across the chasm and across reproductive years, with special attention to the needs of those whose pregnancies signal a risk for chronic illness based on pregnancy complications or substantial SDOH; Enhance existing education and certification mechanisms to equip team members for extended postpartum collaborative practice AND create innovative cross-training for collaborative teams; and Extend the CMS bundled payment in amount and timeframe to cover the entire postpartum year, or create a new reimbursement bundle that allows for multidisciplinary, integrated services after the postpartum period.
2. Develop group models of care	Medicaid Health Plans of America should develop and pilot an in-person model based on lessons learned from CenteringPregnancy and CenteringParenting; Conduct feasibility studies regarding the best setting for group model extended postpartum care–obstetrics, pediatrics, primary care, or other site based on how services for women are organized; and Investigate feasibility of virtual models to accommodate demanding schedules of new mothers, transportation and childcare issues, and geographic distances.
3. Create patient-centered Women’s Health Homes	Fund new models for comprehensive primary care (structural transformation), and Use CMS innovation program authority to support WHHs to provide structure for connectivity and integration in women’s health care before, during, and after pregnancy for at least 1 and up to 3 years, to be piloted by Medicaid Health Plans of America.
4. Develop/implement cross-training models for IPE	Create/sustain Regional/National Training Centers, led by representatives of all the components of the newly expanded workforce, to design competency-based training modules for the postpartum year and conduct innovative, experiential team-based training; Incorporate BtC competencies and resources into existing training and certification processes for doulas, CHWs, and patient navigators (peers) to tie together maternity and primary care; Identify opportunities for cross-training community-based caregivers (CHWs, doulas, patient navigators); and Enhance competencies for Nurse-Midwifery and Advanced Practice Nursing Education Programs (including continuing education) to prepare for collaborative practice at the intersection of postpartum and primary care.
IV. Transform health care systems 1. CMS policy reforms	Pass federal and state legislation to extend Medicaid coverage from 60 days post-delivery to12 months for all states, not just those with waivers or expanded Medicaid under the Affordable Care Act. Extend the CMS bundled payment or create new bundled reimbursement for the period between 10 weeks postpartum (last postpartum visit) and 1 year postpartum. Use CMS program authority to support development and evaluation of new ways to support linkage to primary care through pay-for-performance policies that reward: 1)warm handoff between obstetric and primary care providers, and 2) documentation of handoff templates in electronic medical systems. Fund ACO partnerships with CBOs to identify and address local SDOH through CMS Innovations and Expand the Preventing Maternal Deaths Act to require all states to implement MMRCs for both severe maternal morbidity and mortality in order to collect and apply data related to SDOH impact.
2. New quality measures	Design and implement new quality measures for the NQF/HEDIS, including follow-up of gestational diabetes, discharge with blood pressure cuff for gestational hypertension, and documentation of a warm handoff to primary care; Develop a PREM that captures patient experience of implicit bias/racism within maternity and postpartum care and use it as an evaluation tool for an institution to measure its progress toward health equity and accreditation by the JCAHO; The PREM capturing racism/bias and the warm handoff to primary care should be pay-for-performance measures within Medicaid as well as quality metrics within HEDIS for accreditation; Encourage states to use the set of postpartum measures defined by the Physician Consortium for Performance Improvement (i.e., family planning, postpartum depression screening, postpartum glucose screening) following GDM as Medicaid quality measures for the postpartum visit; and Design and implement new quality measures for the NQF/HEDIS that support adoption of the Women’s Clinical Preventive Services covered under the Affordable Care Act, in Medicaid and private insurance;
V. Preserve the narrative through data systems innovations	Develop an electronic record postpartum discharge template with coded fields (i.e., not free text), including specifics about patient risks and key information for the PCP, and preparation for next pregnancy, with a copy for patients; Create structure and support for women to write or narrate significant experiences during pregnancy and childbirth, focused on what they see as most important for providers to hear and what will impact their health and health care going forward; Fund digital technologies (web- and mHealth-based) or a hard-copy Mother’s Health Book geared to promoting follow-up and primary care after pregnancy complications for medical and social stressors; and Pass legislation to require MMRCs in all states and expand scope to include severe maternal morbidity and family interviews and have people with lived experience on review panels.
VI. Align research with women’s lived experience	Develop new funding sources dedicated to Bridging the Chasm (RFAs, cooperative grants, multisource collaborations) in both public and private venues, with review by a special emphasis panel; Develop and test interventions with patient engagement to address the role of social, behavioral, and environmental factors responsible for ethnic, immigrant, racial, and sociodemographic disparities in pregnancy complications; Conduct patient-engaged research to further define what kind of information diverse women with pregnancy complications will want, need, and find easy to use; Evaluate outcomes associated with innovations (e.g., Women’s Health Home model); Test the effectiveness of a multipronged, high-touch approach (e.g., group-based care at intervals throughout the postpartum year, enhanced by frequent in-person or patient-facing technology contacts) to engage women in their own care and facilitate care plans; and Study the impact of providing consistent, comprehensive care to women through an extended postpartum period, in women’s health home models, by practitioner type, within states/regions that extend Medicaid to 12 months postpartum; and NIH should assess investigator qualifications (lived experience and close ties to communities under study) as part of the proposal review process.

Abbreviations: ACO, Accountable Care Organization; BIWOC, Black, indigenous and all other women of color; BtC, Bridge the Chasm; CBOs, community-based organization; CHWs, community health workers; CMS, Centers for Medicaid and Medicare Services; GDM, gestational diabetes; HEDIS, Healthcare Effectiveness Data & Information Set; IPE, interprofessional education; JCAHO, Joint Commission on Accreditation of Health Care Organizations; MMRC, Maternal Mortality Review Committees; NIH, National Institutes of Health; NQF, National Quality Foundation; PCP, primary care provider; PREM, patient reported quality measure; RFA, request for application (NIH); SDOH, social determinants of health; WHH, Women’s Health Homes.