A Clinical–Community Partnership to Improve Home Visiting Referrals and Engagement [A298].

INTRODUCTION: A Michigan integrated health system used clinical–community partnerships to promote health equity and improve population health by increasing referrals and participation in a Medicaid-sponsored enhanced prenatal care (EPC) home visiting program. The statewide program is federally designated and evidence based for reducing the risk for adverse birth outcomes, with a quarter of eligible women enrolled. The objective of this study was to explore early implementation of a quality-improvement initiative to increase EPC referral and enrollment in 16 obstetrics and gynecology practices in eight counties. METHODS: The strategies used were dashboard tracking, shared goals, engagement of OB nurse educators/social workers, and electronic medical records. Referrals and enrollments were tracked from January 1, 2021 to September 30, 2021 in nine obstetrics and gynecology practices, with the goal of referring all Medicaid-insured women and enrolling 50% of eligible referrals, especially women of color at greater risk, to the health system's internal EPC program. From June 1, 2021 to September 30, 2021, seven practices in six counties linked to external health department EPC programs and targeted a 50% referral rate. RESULTS: Overall, practices connected to internal EPC services achieved the 50% enrollment target (1,247 referrals, 744 eligible [60%], with 394 enrolled [53%]). Enrollment ranged from 24% to 62% by site; of these, 49.5% of participants were women of color. Practices connected to external EPC programs achieved a 51% referral rate (568 eligible, 289 referrals). CONCLUSION: The health system increased referral and enrollment of Medicaid-insured pregnant women, many of whom were women of color, into prenatal home visiting. Clinical–community linkages, aligned with Alliance for Innovation on Maternal Health Community Care Initiative goals, can help practices address equity in maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]