Supporting Transitions to Primary care among Under-resourced, Postpartum women: The STEP-UP

ABSTRACT
We will test the effectiveness and fidelity of a technology-enabled, ‘stepped care’ strategy to connect
high-risk, postpartum patients to primary care within under-resourced community health care settings.
Gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) affect up to 8% and 14%
of pregnancies annually in the U.S. While GDM and HDP often resolve post-pregnancy, women with these
disorders remain at increased, long-term risk of adverse cardiometabolic outcomes. Clinical guidelines therefore
recommend that postpartum individuals with prior GDM and/or HDP transition from OB to primary care for
ongoing evaluation and/or treatment. Yet studies show only one third of women with GDM and about half of
women with HDP see a primary care provider within 6 months postpartum. Of those with GDM, only 1 in 5
complete recommended dysglycemia testing. Limited patient understanding of cardiometabolic risks, poor
coordination between OB and primary care, and logistical challenges have been identified as barriers. Women
who are Black, Hispanic, and/or low-income, with less education and/or low health literacy, are less likely to
receive follow-up care. As early detection and treatment of hypertension and dysglycemia reduces disease
progression, complications, and mortality, poor transitions in care is an issue of maternal health equity.
In response, we will implement and test our Supporting Transitions to Primary care among Under-resourced,
Postpartum women (STEP-UP) strategy. STEP-UP leverages available technologies to support transitions within
health centers, from postpartum obstetric to primary care. Specifically, clinical decision support (CDS) in the
EHR will prompt provider counseling on the primary care transition; it will also enable providers to order referrals
and recommended glycemic tests with a single click. Patients will receive language-concordant materials that
reinforce counseling, along with text messages to motivate and remind them to schedule and attend a primary
care visit. STEP-UP was designed to be a low cost and ‘low touch’ intervention, yet while a technology-based
strategy may work for most patients, it will not work for all. A ‘stepped care’ approach that provides additional,
individualized outreach for only those who need it may be necessary. Thus, a centralized outreach coordinator
will provide additional, phone-based support for any patient who has not scheduled a primary care visit by 4
months postpartum. We will test STEP-UP vs. usual care in a stepped-wedge trial at 4 large safety-net health
centers. Our aims are to: 1) Test the effectiveness of STEP-UP, compared to usual care, to improve: a) primary
care visit completion among women with prior GDM and/or HDP, b) testing for dysglycemia among women with
prior GDM, and c) detection of dysglycemia and hypertension cases among women with prior GDM and/or HDP.
We will also: 2) Investigate the heterogeneity of STEP-UP intervention effects by patients’ race, ethnicity, and
language; and 3) Assess the reach, adoption, implementation, maintenance and costs of STEP-UP components.
If successful, STEP-UP can be readily disseminated to community health centers nationwide.

Grant Number: 1R01HL168832-01
NIH Institute/Center: NIH
Principal Investigator: Stacy Bailey