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Rural Health Information Hub

HRSA Rural Maternal Health Initiatives

Duration: approximately minutes

Featured Speakers

Kristen Dillon Kristen Dillon, MD, FAAFP, Chief Medical Officer, Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services
Carla Haddad Carla Haddad, MPH, Director, Health Resources and Services Administration (HRSA) Enhancing Maternal Health Initiative, U.S. Department of Health and Human Services
Brittney Roy Brittney Roy, MPA, Program Director, National Governors Association
Karla Weng Karla Weng, MPH, CPHQ, Director of Program Management, Stratis Health

This webinar is the final installment in a rural maternal health webinar series hosted jointly by the Health Resources and Services Administration's (HRSA) Federal Office of Rural Health Policy (FORHP) and the Rural Health Information Hub. Building on topics and resources previously covered in the series, including achieving the Birthing-Friendly Hospital Designation from the Centers for Medicare and Medicaid Services (CMS), working with Perinatal Quality Collaboratives (PQCs), implementing patient safety bundles, and obstetric readiness for rural facilities without birthing units, this webinar will highlight various maternal health initiatives within HRSA. Experts will discuss HRSA Enhancing Maternal Care Initiative, the National Governors Association (NGA) rural maternal health collaborative, and a FORHP project that explored rural opportunities for maternal health quality.

From This Webinar


Kristine Sande: I'm Kristine Sande, the program director of the Rural Health Information Hub. This is the final installment in a series that we're hosting in collaboration with the Federal Office of Rural Health Policy on Rural Maternal Health. Today's webinar will focus on rural maternal health initiatives sponsored by the Health Resources and Services Administration. We have provided a PDF copy of the presentation on the RHIhub website, and that's accessible through the URL on your screen. And now I'd like to introduce our co-host for this series, Dr. Kristen Dillon.

Kristen is the chief medical officer at the Federal Office of Rural Health Policy. Dr. Dillon is a family physician with several decades experience working in rural communities. Her responsibilities include advising on clinical care and the rural impacts of federal policy. In addition, she works with grantees, technical assistance providers, state offices of rural health and other stakeholders to improve the stability and capacity of rural communities' health systems. With that, I'll turn it over to Dr. Dillon.

Kristen Dillon: Thank you, Kristine, for that lovely introduction and I'm so grateful to our partners at RHIhub for being our host, tech support, co-organizers, and also the ongoing repository of the recordings of all of these webinars in the series easily available on the RHIhub website.

So, our office, the Federal Office of Rural Health Policy sits in the Health Resources and Services Administration known as HRSA in the Federal Government's Department of Health and Human Services. So, our mission includes improving access for rural communities to healthcare and fostering care that's effective, equitable, safe, and high quality.

With that goal in mind, some of the highest priority work that I and many of my colleagues are doing right now is working to advance maternity care in our country. Many of the dynamics affecting the healthcare of people who live in rural communities add to the challenges that they face while pregnant. Issues like limited access to high-risk specialists, long travel distances, and workforce challenges can all impact rural communities disproportionately.

Today's presentation is the fifth and final in our Rural Maternal Health Learning series. Over a thousand people have registered for one or more of the sessions, and I'm just so grateful to everyone who took time out of their demanding work lives to join us. We've covered the context and challenges facing rural maternal health, the opportunity for hospitals to advance their care through the new birthing-friendly hospital designation, and strategies for hospitals without birth units to meet the needs of pregnant, birthing and postpartum patients who present for care.

Today, we'll hear about the ways that we here in the federal government and others working on a nationwide scale are advancing solutions. Our session today will help pull together what we've covered so far and bring us all to gaze forward as we advance towards solutions and resolution of these situations. It's my pleasure to introduce our speakers for today's webinar.

Carla Haddad has over 15 years of experience managing high-profile domestic and global public health strategic initiatives. She currently leads HRSA's Enhancing Maternal Health Initiative, an effort aimed to accelerate HRSA's maternal health work to address maternal mortality and related disparities in parts of the country where there's higher need and where HRSA has programs that can work together to help advance better outcomes. Before taking on this role, Carla was the director of HRSA's Office of Global Health, where she served as a President's Emergency Plan for AIDS Relief deputy principal and oversaw global health programming in 13 countries. Prior to that, Carla was chief of staff in the US Department of Health and Human Services Office of the Assistant Secretary for Health. Carla holds a bachelor's degree in biopsychology and a master of public health degree in health management and policy from the University of Michigan.

Next, Brittany Roy, serves as a program director for the National Governors Association, where she oversees initiatives focused on public health and healthcare delivery. In her role, she spearheads policy efforts to tackle the multifaceted challenges within the public health and healthcare landscape. These include addressing social determinants of health, promoting disease prevention and management, enhancing cost and coverage mechanisms, advancing health equity, and maternal and child health.

Roy supports governors and their advisors in shaping policies that have a tangible impact on the health and wellbeing of communities across the nation. Prior to her tenure at the NGA, Roy served as a senior advisor in the Arkansas Governor's Office covering public health, welfare and labor. Through her previous roles, she honed her policy development and advocacy skills, gained invaluable experience that informs her current work at the intersection of health care and public policy. Roy's dedication to improving health outcomes and fostering equitable access to healthcare underscores her commitment to serving the greater good and driving positive change at both the state and national levels.

And our final presenter, Karla Weng, leads the organization's rural-focused programs at Stratis Health. For more than 20 years, Karla has led a wide variety of national, state and local initiatives supporting rural hospitals and clinicians in improving quality and population health. These include implementing quality management methods, developing palliative care services, preventing readmissions, and transitioning to value-based care. Karla is a frequent presenter at meetings and conferences focused on improving rural health quality and value-based care. She holds a master's degree in public health administration from the University of Minnesota, an undergraduate degree in community health education from Minnesota State University Moorhead, and is a certified professional in healthcare quality.

And with that, I'll turn it over to Carla.

Carla Haddad: Thank you so much, Kristen. And hi, everyone. It's great to be with you all today. I'm Carla Haddad and I'm the director of the Enhancing Maternal Health Initiative at the Health Resources and Services Administration or HRSA. Improving maternal health outcomes is one of our agency's key priorities. And over the next 10 minutes, what I plan to do is give you a high-level snapshot of HRSA and how we support maternal health across our various programs across the country. And then, I'll dive in a little bit deeper to provide an overview of this new initiative, the Enhancing Maternal Health Initiative, and what we've done to date and what's to come with that.

First, just a very quick snapshot of our agency, HRSA, and the communities that we support. HRSA programs provide healthcare to the nation's highest need communities, and our programs support millions and millions of people with low income, people with HIV, rural communities, transplant patients, just to name a few. This also includes over 58 million pregnant women, infants and children through our various maternal health programs.

And I'd like to take just a moment to highlight a few of these programs to give you a sense of the breadth of how we cover and how we work to improve maternal health outcomes, not only in our dedicated Maternal and Child Health Bureau, but across all of the offices and bureaus and programs that we support.

First, the Title V Maternal and Child Health Block Grant. This is an example of how partnerships between the federal government, states, and communities help improve access to high-quality healthcare services for both mothers and their families. So, HRSA provides funds directly to states which then have the flexibility to determine how best to use these funds in their communities based on need.

Complementing the Title V program, we have a Healthy Start program which supports more community-based strategies for improving a woman's health before, during, and after pregnancy, and really aims to advance equity and reduce racial and ethnic differences in rates of infant deaths. These services can include health education, preventive care, screenings for depression, intimate partner violence, and well-women care.

And the program also funds community-based doulas who support the social and the physical needs of pregnant women to ensure that they feel supported throughout the whole process and are connected to a trusted source of care.

Additionally, we have the Maternal, Infant, and Early Childhood Home Visiting program that HRSA supports where we support evidence-based home visiting services for pregnant women and parents with young children. And this program is unique in that it emphasizes a two-generation approach with its dual focus on both the caregivers and the children. We will have home visitors working with families to help them achieve their goals while creating that stable and enriching environment for their children.

And outside of these flagship Maternal and Child Health programs, we know that health centers across the country play a critical role in supporting maternal health. In 2022, health centers served nearly 560,000 prenatal care patients nationally, and these numbers continue to grow each year.

HRSA is also working to bolster the maternal workforce and to help address gaps in access to maternity care, especially in under-resourced communities, we actually developed a way to help identify maternity care target areas, which are essentially areas with the greatest need for maternity care health professionals. And what we do is we link our National Health Service Corps and link providers to those underserved communities to make sure they help fill those gaps where there's greatest need.

And of course, as many of you know who are on the call today, we know that moms and families in rural communities often face unique barriers in accessing the maternal care that they need. And one program that was implemented from the Federal Office of Rural Health Policy is the Rural Maternity and Obstetrics Management Strategies program or RMOMS, which is really aimed to increase access to maternal and obstetrics care in rural communities and provide funding to grantees across the country to implement sustainable delivery models in rural hospitals and in communities.

I wanted to just highlight a few of the many, many programs we have across HRSA that touch on maternal health and advancing maternal health outcomes in some capacity to give you a sense of the breadth of our work, and that this issue is truly cross-cutting at an agency focus.

So, more about the new initiative that was launched, the Enhancing Maternal Health Initiative. The idea around this initiative was really generated from the recognition that while HRSA makes significant maternal health investments across our programs and in communities across the country, we're still faced with the unfortunate reality that the majority of pregnancy-related deaths in the US are preventable, and there are striking disparities in these maternal health outcomes.

With this in mind, in January of 2024, HRSA launched a year-long Enhancing Maternal Health Initiative that's really focused on expanding access to maternal care, growing the maternal care workforce, supporting maternal mental health, and also addressing the important social supports that are vital to safe pregnancies.

And through this initiative, we focused on 11 states as well as DC and selected these states based on a few different criteria. One, we looked to see where HRSA had significant investments across many of our programs. Two, we looked to see where there might be unique or good opportunities for new partnerships and collaborations across organizations in those particular states. And then, we also took a look at the maternal mortality and morbidity data to determine where there might be higher need, for example, where there might be workforce shortages or where the maternal mortality rates are especially concerning, et cetera, and took all of those into consideration and identified the states and the communities that we selected for this initiative.

We had a kickoff event in January in DC with grantees from these 11 states and DC, which really helped set the stage and brought key players to the table to share their personal perspectives on maternal healthcare and support, as well as the innovative ways that HRSA grantees are making an impact in this area. And throughout the year through this initiative, HRSA will be bringing together our grantees as well as women with lived experience providers and other key stakeholders from across the states of focus to help foster the cross-program connections and the cross-state relationships to really drive this work forward even more and work to improve maternal health outcomes.

There are three overarching goals of the initiative. The first one is around, and I mentioned this in the previous slide, but really working to foster those new relationships, partnerships, collaborations among our HRSA program grantees across our programs in high-need areas to help drive this forward. And we're doing this primarily through the statewide convenings that we plan to hold over the course of the year.

Our second goal is to work on developing metrics and tracking metrics for enhancing cross-HRSA activities to address maternal mortality and help improve maternal health. So, we're in the process of developing a few internal metrics that cross our programs to track over time. For example, we're especially interested in understanding the percentage of safety net providers in health centers and other sites who are sharing information on key resources like HRSA's Maternal Mental Health Hotline with patients, and how we can increase those numbers over time.

And the third goal of the initiative or third track is around internal capacity building, thinking about how we can really strengthen the capacity of our HRSA staff to make them feel more comfortable, more confident, and have a full understanding of the breadth of work taking place across the agency and all the resources that exists or could be helpful to the grantees and stakeholders that they speak to every day so that they can make those connections in their daily interactions.

As I noted, there are 11 states, as well as DC that have been selected to be a part of this initiative. And this map gives you a good sense of which states they're in. I've listed them as well. Each of these states, again, have multiple HRSA-funded maternal health focused programs. And our goal is really to support these states and our grantees and stakeholders in these communities to make those linkages to each other to see how they can increase the impact on the ground.

The next two slides, I'll just cover very briefly the first two state convenings that we've been able to hold and we'll give you a glimpse into what's to come. Our first, Enhancing Maternal Health Initiatives state-based convening took place in Missouri in St. Louis. And it was really great, and that we brought together roughly 40 representatives across all of our key maternal health programs and initiatives.

And we also invited community leaders, state leaders, providers, and mothers with lived experience to talk about both how they provide services to their communities and their perspectives on how they receive those services as well with those with lived experience. And of course, with that conversation came in opportunities that exist where we can think about how we can do our work better to strengthen this work across the state.

In terms of the format of the convening, we held a roundtable discussion in the morning, which is really great, and we're able to hear the voices of the mothers and those with lived experience to help inform and drive that conversation. And that was then followed by a hands-on action planning meeting in the afternoon where we broke into different groups to dive deeper into key topics.

And the goal of the day was really for folks to leave with key actions and commitments that they can make in their communities to further support maternal health, including forming new partnerships with other participants who were able to attend the convening. And we did hear firsthand from those who attended that it was just a great way for them to meet others nearby and across the state who are doing similar work or complementary work to see how they could make those connections, referrals, or collaborate to make greater progress.

Following the Missouri convening, we held our Georgia convening on April 29th, and this is a special one and that we were able to announce $105 million in new funding to support more than 100 community-based organizations through the Healthy Start Program to drive this work forward. And actually six of the Healthy Start awardees were in the state of Georgia, and that included Southside Medical Center, which graciously hosted the convening at their site in Atlanta.

It was really great news to share with the group. We had a similar structure for the day where we held the roundtable in the morning and that action planning discussion in the afternoon. And just looking ahead, we're working hard toward our next Tuesday convenings in Flagstaff, Arizona on June 3rd and Bozeman Montana on June 11th. And of course, the other states will follow after that.

Before I end, one thing we make sure to do in each of the convenings is to help raise awareness of an incredible resource that exists to support new mothers and their families. And that is the National Maternal Mental Health Hotline. I'd like to encourage all of you to help spread awareness of this tool. It's an incredible resource. When a person in need calls or texts, 1-833-TLC-MAMA, they're connected with a mental health counselor. It is available in English and Spanish, and there are multiple languages that can be interpreted as well.

We've supported thousands and thousands of people through this hotline, but I know we can do more to reach more people who are in need or who could benefit from this resource and do that through new and strengthened partnerships, including with many of you joining today. We can make sure that every new mom has the information they need or has someone to talk to when they're feeling down or need that extra support. Please do spread the word about this to those that you think could benefit.

And on the next slide, we actually have a variety of promotional materials related to the hotline. If you just scan the QR code here, you can find posters, wallet cards, magnets, and other key printed tools that you can distribute in your communities. These are all free materials. You can also order them for mailing as well. A lot of different ways to use these resources.

This concludes my presentation. Thank you so much for your time, and I'm happy to take any questions during the Q&A session. Thanks so much.

Brittney Roy: So glad to be on with you guys today. My name is Brittney Roy and I serve as program director covering a lot of health topics here at NGA, but primarily public health and healthcare delivery. For those of you on the call that may not be very familiar with the National Governors Association, we were founded in 1908 and we are the voice of the leaders of 55 states, territories, and Commonwealths NGA is the premier and only organization that supports governors and their cabinet members. And those cabinet members support a whole host of state and policy experts that we help assist as well.

We're primarily broken up into two arms, so our governor relations arm, which does a lot of our work and advocacy to Congress and to the administration and the Center for Best Practices, which is where I sit. So, we think of us as the extra set of hands for governor's advisors, whether it is for health, education, homeland security, infrastructure, you name it.

I want to share a little bit with you guys about our maternal and child health learning collaborative focusing on maternal and child health outcomes in rural America. Last year, we spent time during our chairs initiative with Governor Murphy and First Lady Tammy Murphy of New Jersey, focusing on maternal and child health issues within the states. It was a priority for First Lady Tammy Murphy to lead on this work.

From that work, we produced a playbook, a very practical playbook, if you will, with strategies and solutions for governors to consider implementing to reduce the health disparities faced within this population. From that initiative brings us over to today, our learning collaborative. We have partnered with HRSA to provide technical assistance to nine states... well, eight states, one territory. We have Alabama, Michigan, Nevada, American Samoa, Missouri, Washington, Illinois, Pennsylvania, and Virginia.

And the way that we do learning collaboratives at NGA, we ask the governor to tell us what they would like to work on within a specific policy area. And these governors responded very well to our request to provide technical assistance. We have broken out our cohort states and territories into three main buckets, and this was at the request of the offices.

We have some states focusing on hospital systems and Medicaid. We have some focusing on strategic planning and collaboration, and we have others focusing on substance use and behavioral health. And I mentioned at the start of this conversation, the emphasis is really on rural America. And so, what within those categories and buckets could governors be focusing on? We've had state teams mention everything from perinatal workforce capacity, access to care, especially behavioral health supports.

We've had states and one territory mentioned that they needed help creating a maternal and child health strategic plan to move their state forward. We have some focusing on Medicaid levers to improve care access. What does patient education and awareness look like? And I will say NGA, our sweet spot is our convening power, right? If the governors say, "We see that there is an issue," we come in and say, "Hey, we can help you figure out how to solve that problem." So, through this year-long collaborative, the goal is to have some type of legislative ask or a rule change that is at the discretion of the governor's office. We just work to support to make sure that those things happen.

These state teams are pretty large, which I think goes to show the dedication that many of the health advisors on this project have. The state teams include the Governor's Health and Human Services advisors, as well as someone from their Department of Health or Human Services, typically their Title V director or a Medicaid secretary.

We have individuals with lived experience on the teams as well. And we are hoping that by the end of this project, we will have that strategic plan to turn back over to the governor and then go into year two to figure out how to actually begin to implement some of those policy areas that were identified. And I will pause there.

Karla Weng: Thanks, everyone. It's a pleasure to be with you here today. I'm excited to share with you some of the work that our Rural Health Value team did looking into the birthing-friendly hospital designation. Just a little context of the Rural Health Value team is a collaboration between the RUPRI Center at the University of Iowa and Stratis Health. We've been funded by the Federal Office of Rural Health Policy for about a dozen years now, and our focus is to facilitate provider and community transitions from volume-based care to value-based care. We do a lot of work around developing tools and resources, helping interpret and understand how policy from a rural lens, disseminating best practices, sharing direct technical assistance, and sharing rural experiences.

From that health policy and sharing rural experiences lens, when CMS came out with the announcement that they were going to do the birthing-friendly hospital designation, FORHP asked our team to do some sense-making and understanding about what those potential implications and barriers might be for rural hospital participation in that program. Just again, a little bit of level setting of what we're talking about by the birthing-friendly designation. It is a new CMS designation. It's posted on the Care Compare website that's a public-facing website.

If I search the hospital in my community, I'm going to get a one-page summary that gives me quality information on local hospitals that I can look at. And so, there's a designation. I've got the little symbol here on the page that would indicate high-quality maternity care. This was newly just released last year. At this point to earn the designation is solely based on the reporting of the CMS Maternal Morbidity Structural Measure, which includes hospitals attestation once per year of activities in two different areas.

It's a yes, no, not applicable question, but it's a two-part question that they're responding to when they attest to. For hospitals to say yes, they would say that they're participating in a statewide or national Perinatal Quality Improvement Collaborative program and that they're implementing patient safety practices or care bundles to address complications occurring during pregnancy and birth. At this point, you would log in through your hospital quality reporting system, you'd go to web-based measures, and you would have an option to say yes, no or not applicable. Hospitals that don't do labor and delivery services would select the not applicable. The measure is required under the Inpatient Quality Reporting Program for prospective payment system hospitals, but critical access hospitals can voluntarily report the measure as well.

CMS attached the designation to that measure for the first time last year. The reporting came out on the CMS Care Compare site in November of 2023. And the designation that's currently posted is based on the calendar year 2022 status.

When the measure gets reported, for example, for the calendar year 2023 activities, the reporting was due May 15th of 2024. It's about a year behind by the time the information is posted just by the reporting process. They release the status on November 2023 based on what people had reported of as activities in 2022. There is actually an interactive map and a list of hospitals that you can get at the link in the slides

For the initial designation period, critical access hospitals, several of them did report. 158 critical access hospitals did meet the birthing or earned the birthing-friendly designation, and about 250 critical access hospitals indicated that the measure wasn't applicable because they don't have a birthing unit. Again, there's three options. There's a yes, there's a no, there's a not applicable.

For those of you that work in the critical access hospital space, you're probably aware that there's about 1,366, I think, the number is right now, critical access hospitals. In this last year's reporting, there was only about a third of the critical access hospitals that reported the measure. The hospital reporting for calendar year 2023 and the updates to the designation based on that reporting will be reported later this year on Care Compare likely in the fall release.

There is some links to more information about the measure and the attestation guide there at the bottom of the slide. The reporting for calendar year 2023 was just due last week, May 15th. FORHP asked our team to gather feedback directly from rural hospitals to try to get a better understanding about what thoughts or awareness of this CMS birthing-friendly hospital.

Last spring, we did surveys and interviews targeting critical access hospitals and small rural hospitals that provide labor and delivery services. We were really focused in on trying to reach those that were providing labor and delivery services. And we did outreach to more than 80 facilities across 22 states.

I have to pause and say thank you to the State Office of Rural Health and State Hospital Association staff that helped us identify appropriate hospital contacts for this effort.

I reached out to colleagues in 22 states and asked them to help me connect to the right people in different facilities across the country to get them the information around this survey. And they all responded and provided assistance to that. We had about a 50% response rate to that survey, and then we did a follow-up of another 11 interviews, which really informed our findings. We really targeted both a mix of hospitals that did meet and did not meet the designation criteria.

All of that work took place last spring. I think we did the interviews actually last May. What I'm sharing with you was current status about a year ago. So, some of what we found, I don't know that this is actually a true finding of the survey, but I think it was certainly highlighted or important to call out, is that we really did recognize through the feedback that we got, that there's really wide variation in staffing models and capacity across rural hospitals.

What labor and delivery looks like in a rural hospital can be vastly different. So for the hospitals that we gathered feedback from, there was a range in the estimated annual deliveries of 60 to 600. That's a big range and so can look very different, depending on where you fall in that spectrum. We also heard, again, not particularly surprising, but did just highlight the fact that there's a pretty wide range of medical models for how people are staffing their labor and delivery services.

Some were using predominantly OB-GYN, some were using family practice, some were using certified nurse midwives. Some had a combination of the above, but that there's really widely varying structures for what that medical model looks like. And that will have implication when we're thinking about how some of these safety bundles might get rolled out or who might be sitting on teams or how you might be supporting the quality improvement activities.

We also heard some pretty wide variation in terms of understanding of the reporting and awareness related to the designation. About half of the people that responded to the survey shared with us that until they got the survey, they were not aware of the birthing-friendly designation. Again, last year was the first year it was coming out, it had not yet been released, but that there was some, I would say general lack of awareness of what the designation was, that it was attached to the maternal morbidity structural measure and to some opportunities related to awareness for that.

We also heard some confusion over, there's a separate long-standing baby-friendly designation, which is different. Some questions about how those two things fit together, and then also some questions around understanding of the measure that the designation is being based on and that criteria. What does it mean if you're a part of a health system that participates in a perinatal quality collaborative? And so, some just clarity pieces around what that looks like to respond as a yes to that.

I have sprinkled in here just a couple of quotes from the survey and the interviews because I wanted to give you a little bit of flavor. And this one I think really just spoke to me is that, "As a rural hospital, I want our patients to feel they're getting the most up-to-date evidence-based care as they would at any other facility that provides OB services. Just because we're small doesn't mean we don't know what we were doing." And I just love that quote because I think it's very illustrative of rural healthcare in general that we're not looking for standards to be different in rural, but we're trying to make sure and understand that the designations and the standards are relevant in some of our rural communities.

We also asked all of the folks around what their engagement in perinatal quality collaborative activities looked like. And again, we found really wide variation across the states. And I think there's wide variation in perinatal quality collaborative activities across the state.

I think they're a fantastic resource. There is one now in every state, but what they're actually implementing, how they're structured, what their resources are can look vastly different. How that works in terms of engagement and participation from rural hospitals also varies.

Again, we heard some questions about awareness and access for rural hospital participation, whether or not rural hospitals were aware of the perinatal quality collaborative activities, whether or not they had access or felt that they had time and capacity to engage in that also varied.

And then, one of the last pieces we heard was some questions or comments around relevance of the activities and focus areas for hospitals with limited resources. A couple examples specifically came up multiple times when we were thinking about some of the bundles that are patient safety bundles that have been developed and they're amazing resources that come out of the AIM team, but that they're perhaps structured or developed by hospitals with very different capacity.

A couple examples that came up was that one of the bundles talks about the level of blood products that should be available for severe hemorrhage, and that outweighs what they might actually have available for blood products in a rural hospital. Another example was that some of the bundles might indicate that the next step if this is happening is to call NICU. If you're in a rural hospital, you likely don't have a NICU. So, what does that look like?

Opportunities to better understand and ensure that some of those policies and procedures and the examples of those might be relevant in terms of the context of rural hospitals. We also did some looking at the potential implications around rural hospitals related to the birthing-friendly hospital designation and or if they weren't able to reach that birthing-friendly hospital designation. I would say at this point, I'm not sure that we really know that there are implications, but here's a couple areas that we dug into a little bit.

There is the potential that it could become a factor in contracting. I don't think we're there anywhere. I'm not hearing that anywhere across the country at this point. But we know that in addition to the focus on the Care Compare site of the highlight of the birthing-friendly hospital designation, we know that the federal benefit carriers, so if you're a carrier that offers insurance for folks with federal benefits, they're highlighting the birthing-friendly designation.

AHIP, the America's Health Insurance Plans, is putting the birthing-friendly designation in all of their provider directories. The designation has legs, I would say, beyond the CMS Care Compare site. And so, then, we're also at this point, unclear of whether or not... at some point somebody might say, "We're not going to contract with this hospital if they don't have a birthing-friendly hospital designation." We're not there, but we're just keeping awareness to that.

We did hear that... Oh, it's probably been a dozen years ago now when the patient experience star ratings first came out and we were hearing from some hospitals that insurers were telling them they wouldn't contract with them if they didn't have a three-star rating on their HCAHP scores, patient experience scores, which for a lot of rural hospitals, they just don't have the volume to meet the threshold for that calculation. So, just trying to be aware of what some of the implications could potentially be.

At this point, we're also not aware of, but it is potentially likely that there could be reimbursement consequences if there's hospitals that aren't meeting that designation, whether or not it's a lower rate, whether or not it gets built into value-based purchasing contracts. We're not hearing that at this point, but it is something to be aware of and considering. And then, related, there's also a consumer choice component, so unclear how many hospital, how many folks are looking at hospital ratings are looking for a designation as they're selecting a hospital for their labor and delivery needs. If I'm in a particularly remote rural area, it might not really matter to me. But if I'm somewhere where I might actually have access to a variety of choices, it might be something that I'm looking at. And we just want to help ensure that rural hospitals have the resources and the ability to meet those designation as appropriate.

CMS has also indicated that there will likely be future updates to the designation criteria. So, right now, it really is just based on that severe morbidity structural measure.

There are a couple of electronic clinical quality measures related to cesarean birth rates and complications that are going to be available soon. Those are potentials that they might get rolled into the criteria. There's other areas that CMS has indicated that they might consider. I think it's probably not a bad thing to increase the robustness of the designation criteria with the lens of we just want to make sure that we're not structuring criteria or structuring it such that rural hospitals are unable to meet it based on the resources that they have available.

Some opportunities. Certainly, I think there's continued opportunities to increase rural hospital access to and engagement and perinatal quality collaborative support and activities. I commented briefly already about potential adaptations to tools and processes that better align with resources in rural hospitals. So, depending on what's happening in terms of perinatal quality collaborative participation in your state, some states have been at the PQC for quite some time and rural hospitals may be more newer in joining that.

And as perinatal quality collaborative roll through different types of initiatives over time, it was raised in some of our discussions wondering whether or not there might be catch up options to support rural hospitals that might not have been participating a couple of years ago when they implemented a particularly key patient safety bundle. So, what does that look like if I'm new to the perinatal quality collaborative, but they're no longer working on something that might be important to me? So, some opportunities there.

And then, a little bit of confusion and a lack of understanding of what does it look like to engage rural hospitals either independently or part as a broader health system initiative. We did talk to a handful of hospitals who the rural hospital is located in one state and the tertiary parent hospital is located in a different state. And what does it mean if the tertiary hospital is participating in that state's PQC for this hospital? What does that look like in terms of how that's networked and whether or not they're meeting those criteria appropriately? So, continuing to think about what are opportunities to engage both independent rural hospitals and system-based rural hospitals.

Finally, just encouraging continued expanded focus area as part of the birthing-friendly designation. Thinking about pre and post-natal care needs, access and best practices, including strategies to help address health related social needs. I know there's a ton of work happening with that with several of the HRSA programs, but how does that fit into this broader scope of considering birthing-friendly hospital designation?

And then, I have to call out because that's such an amazing resource, the AIM Obstetric Emergency Readiness Resource Kit that is available. This is targeted particularly for hospitals that are not intentionally doing labor and delivery services, but I think there's opportunities for lower resourced hospitals to be able to take some of that resource and information and apply it as they're looking at patient safety bundles and opportunities to improve in rural.

My last couple slides are resources to make sure folks know where they can find information that is available.

Kristen Dillon: Thank you so much, Karla, and to all our presenters today. Today, we've heard about HRSA's work in advancing maternal health, the Enhancing Maternal Health Initiative, other projects, and also the so important maternal mental health hotline. That hotline just passed its second anniversary this past Mother's Day, and it's received over 33,000 calls from people seeking help.

We also heard about the National Governors Association and got an example of the hands-on work that they do at the state level with governor's office staff and administration staff to harness the authority and the influence that exists at each level of these different structures.

And then, finally, Karla, Stratis Health, thanks for elevating your on-the-ground expertise to understand the pragmatic implications of the actions that are being taken and also the potential consequences of this move to designate hospitals and hopefully improve care and safety. This may be the end of the webinar series, but it's by no means the end of the work. Today, we've shared information about new and ongoing initiatives.

I thank you all who are here with us today for the work you're doing at all levels to advance the help of babies and birthing people, and extend the invitation to engage with the work we've shared today, as well as what we've covered in the last four installments in this series, so that we can all join together to continue to move this work forward. We have also pulled together what we feel like are some of the key resources for hospitals with birth units. These are some of the high points and the places to start to advance care in your hospital, your birth unit, in your community.

For hospitals without birth units, these are what we feel may be some key starting points to advance that work forward. And we are continuing to identify the needs in this area and the appropriate responses so that we can continue to build a safety net for pregnant postpartum and birthing people no matter what type of a facility they present to when they're seeking care.

With that, I will turn it back to our hosts to field any questions.

Kristine Sande: And then for our HRSA folks, where is the best place to review grant opportunities from HRSA or with HRSA?

Kristen Dillon: So, going to will allow anyone to navigate to the open grant opportunities. And then, the other thing that can happen there is it's really easy to sign up for a HRSA newsletter. And within that, you can specify the FORHP announcements. We send out announcements every week. It's a very succinct email that outlines any new or still open webinar opportunities, as well as a bunch of other opportunities for education and resources.

Kristine Sande: And I would note too that RHIhub also features HRSA opportunities on a weekly basis.

Carla Haddad: Like Kristen, you mentioned the HRSA eNews that folks can subscribe to, which is really a bi-weekly update on all things going on across HRSA. And they do give, of course, a nod to new notice of funding opportunities that are available to review. I encourage you all to subscribe to that for HRSA updates and more information,

Kristen Dillon: I thanked our speakers. I'm really grateful to you all at our RHIhub and to our attendees and all the people working across our country to improve the health and healthcare available to rural residents in America.

Kristine Sande: The slides from today's webinar are available on our website, Thanks again and have a great day.