Rural Health Care Services Outreach Grant Program - This project aims to optimize care transitions for individuals diagnosed with hypertensive disorders of pregnancy (HDP) to improve cardiovascular disease (CVD) outcomes. Our program, entitled Postpartum Hypertension Education, Awareness, Risk Reduction, and Transitions of Care (Postpartum HEART), will target rural and underserved populations in Mercer and Venango Counties in rural Pennsylvania. The target population will include approximately 1,200 patients diagnosed with HDP who deliver at UPMC Horizon in Mercer County and UPMC Northwest in Venango County. These counties rank among the lowest in health outcomes statewide and face substantial barriers to accessing health care and high rates of CVD-related morbidity, premature mortality, and unmet social needs. This project aligns with HRSA’s goals for improving health outcomes in underserved regions and qualifies for each funding preference as it will serve individuals in Health Professional Shortage Areas and Medically Underserved Areas/Communities and focuses on optimizing the transition of individuals with HDP from obstetric (OB) to primary care (PC) for long-term CVD prevention, monitoring, and management. The proposed project will achieve four goals: 1. Prepare: Optimize Postpartum HEART processes and workflows to ensure they meet the needs of rural patients, providers, and other stakeholders. 2. Implement and Evaluate: Implement Postpartum HEART and evaluate key metrics and outcomes to measure the success of the program. 3. Sustain: Identify promising strategies to sustain Postpartum HEART. 4. Disseminate: Disseminate information about HDP, CVD risk, the importance of routine PC, and Postpartum HEART implementation findings and impact to diverse audiences (e.g., patients, providers, payers, policy makers, community organizations, health systems) to raise community awareness and to support program scalability. Postpartum HEART is comprised of three distinct evidence-based approaches to support various aspects of the hypertensive disorder of pregnancy (HDP) care continuum. These include: 1. hypertension remote patient monitoring (RPM) through 6-weeks postpartum; 2. a Virtual Care Center (VCC) visit at 6-weeks postpartum to discuss CVD risk and the importance of routine PC follow-up to prevent CVD; and 3. eConsults, which will be developed by the VCC provider and sent directly to the patient’s PC provider to support the provision of guideline-based care after HDP. Implementing these three strategies will mitigate the immediate risks of HDP on severe maternal morbidity and mortality (RPM), facilitate the transition of care from OB to PC providers (VCC and eConsults), and ensure the delivery of continuous, guideline-based cardiovascular care by PC providers (eConsults). Outcomes to be assessed at 1-year postpartum include blood pressure control, PC provider visit, receipt of all/some components of Life’s Essential 8, pregnancy status, HDP/CVD-related emergency department use or hospitalizations, and severe HDP/CVD-related outcomes (e.g., stroke, heart failure). This project is supported by a strong consortium led by the UPMC Center for High-Value Health Care (CHVHC), in partnership with UPMC’s Womens Health Service Line, UPMC Horizon, UPMC Northwest, Adagio Health, the Pennsylvania Association of Community Health Centers (PACHC), and rural primary care practices. Together, these organizations bring extensive experience in serving rural populations and their collective expertise spans pregnancy and postpartum health, RPM/telehealth, addressing social needs, stakeholder engagement, program evaluation, quality improvement, and OB and PC care. With extensive experience in managing HRSA-funded projects and leading multi-partner collaborations, CHVHC will oversee the project's implementation. Having successfully executed over $64 million in external funding, CHVHC has a proven track record of managing large, complex projects in rural settings.
