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SAN DIEGO — SSM Health is replicating across its four-state footprint a screening program to identify and address social needs that affect health among maternal care patients.

"We need to continue to invest in these women because it's the right thing to do and should become the new standard of care," said Elizabeth Voss, an SSM Health obstetrics nurse navigator based in Madison, Wisconsin, where the program started.

During a session at the 2024 Catholic Health Assembly, Voss and Stacy Dorris, an SSM Health obstetrics nurse navigator in St. Louis, shared why the system began the screenings to address health inequities, how the screenings are done and some of the outcomes.

Voss noted that social factors such as income, education and access to medical care long have been recognized as major determinants of health. SSM Health started its social needs screenings in Dane County, Wisconsin, where Madison is located, in 2022 in partnership with the Dane County Health Council. The intent was to improve health outcomes for Black maternal care patients and infants.

Dane County has one of the highest Black infant mortality rates in Wisconsin, Voss noted. That rate was at 12.9 per 1,000 births in 2021-2023. Meanwhile, across Wisconsin, Black infants are three times as likely as white infants to die before their first birthday. Their maternal mortality rate for Black women — defined as death during pregnancy or up to 42 days afterward — is five times that of white mothers.

Start of ConnectRx
Those numbers led to the launch of a program called ConnectRx, which got funding from several public and private sources.

Voss noted that ConnectRx involves all the health care systems in Madison. "They all got together to have a common goal to reduce preterm births and low birth rates and improve infant mortality for Black women in Dane County," she said. "Black women were a crucial part of our team collaborating with us on how the program was to run and operate."

Working with Epic, the electronic medical record company, the partners created a screening questionnaire that covers five domains: financial strain, food insecurity, transportation needs, housing instability and stress. The questions are posed to patients at their first obstetrics appointment, at their 28-week prenatal visit and at their postpartum visit.

Based on the patients' answers, Epic generates an individualized social determinants of health "wheel" that reflects what needs the patient is reporting. "The wheel offers a very quick visual for providers to understand what patients might be struggling with," Voss said. "The domains turn red for high risk, yellow for medium and green for low risk."

Care providers use the screenings' findings to alert either nurse navigators or community health workers who can refer the patients to resources and services. Nurse navigators and community health workers use the United Way 211 directory and Unite Us — two social services platforms — to connect patients to services.

Screening expansion
Although ConnectRx was launched specifically to help Black patients get services, SSM Health saw a need for social support among OB patients of every race, Voss said. The system decided to screen all of its Wisconsin OB patients using the same questionnaire.

Voss said 8% of SSM Health's OB patients in Wisconsin are screening positive for social needs. From the start of this year through April, 135 patients were referred to OB nurse navigators for services. Of those in need of food assistance, 81% got a "confirmed referral," meaning a community-based organization made contact with the patient and offered assistance. The help includes enrolling in federal food programs and finding nearby food pantries.

Voss discussed how she helped a young single patient named Kendra who was expecting her second child apply for the federal supplemental nutrition program for women, infants and children, known as WIC.

At first, Voss was assisting with filling out the necessary applications and making the needed phone calls on behalf of the woman. "But by the end of the pregnancy when we would talk she would be so excited to share all she had accomplished on her own since the last time we had spoken," Voss said. "She felt empowered to navigate the system and advocate for herself. By the end of her pregnancy Kendra was able to move into a place of her own."

ZIP code inequities
In St. Louis, SSM Health's support program for expectant mothers and infants also is offered to all patients regardless of race. Dorris discussed the sharp demographic contrasts across St. Louis County. In one county ZIP code, census data shows the population is 78% white, median household income is $90,000 and life expectancy is 85 years. In a county ZIP code 8 miles away, the population is 95% Black, median household income is $15,000 and life expectancy is 67 years.

"Unsurprisingly, these inequities cross over to our maternal population," Dorris said.

For example, across Missouri, the pregnancy-associated death rate among Black women is three times the rate for white women.

In the St. Louis region, screenings done by SSM Health care providers find 35% of maternal health patients have social determinants of health needs, and of those, 80% are Black.

SSM Health uses the Unite Us platform to make patient referrals to community-based organizations in the region, but Dorris said care providers have found gaps in services. "We began creating our own resource directory and formatting it in a way that allows the resources to be easily sent through MyChart or email," she said.

From January through March of this year, care providers in the St. Louis market referred 191 patients to OB nurse navigators for social needs. Of those in need of food assistance, 77% got a confirmed referral.

Dorris and Voss both noted that a barrier to reaching a 100% rate for confirmed referrals is that some patients don't have reliable phone or email access.

'Healing power of presence'
As SSM Health expands the screenings across its footprint — which also includes hospitals and clinics in Oklahoma and Illinois — the system is tracking findings from the first couple years. Among the findings, Dorris said, is that social needs for maternal care patients are high. In St. Louis, for example, 40% of patients reported food insecurity.

Another finding, Dorris said, is that staffing the program is a challenge. SSM Health has assigned nurse navigators to see that the results of screenings lead to referrals and that patients are informed of and assisted with them.

Voss said she believes the screening program not only meets vital needs but also provides vulnerable patients with a comforting human connection.

"Those of us that are in the area have found the work to be both challenging and very rewarding," she said. "I feel this program really embodies SSM Health's mission. I truly appreciate working for an organization that believes in the healing power of presence."