Bridging the Gap From Postpartum to Primary Care

Bridging the Gap From Postpartum to Primary Care: A Behavioral Science Informed Intervention to Improve Chronic Disease Management Among Postpartum Women

National Institute on Aging (NIA), National Bureau of Economic Research, Inc., Massachusetts Institute of Technology

Chronic health conditions affect most older adults. Preventative medicine and risk management strategies, especially when applied earlier in life, are essential to altering the trajectory of a disease and ultimately improving health outcomes. Primary care providers (PCP) often provide most of these services, though younger adults are the least likely to receive primary care. This project leverages a period of high engagement and health activation during an individual's life (pregnancy) to nudge her toward use of primary care after the pregnancy episode. This randomized controlled trial will test the hypothesis that a behavioral science-informed intervention, incorporating defaults and salience, can increase the rates of PCP follow-up within 4 months following a delivery for individual with hypertension, diabetes, obesity. If successful, this intervention could serve as a scalable solution to increase primary care use and preventative health services in a population that currently has low rates of engagement and utilization of these services.

Individuals will be randomized with equal probability into either a treatment or control arm. The intervention combines several features designed to target reasons for low take-up of primary care among postpartum individuals. This project will leverage the potential value of defaults/opt-out, salient information, and reminders to encourage use of primary care. Individuals in both the intervention and control arms will receive information via the study institution's patient portal toward the end of the pregnancy regarding the importance and benefits of primary care in the postpartum year. This information will be similar to, but reinforcing, the information they would receive from their obstetrician about following up with their primary care physician. In addition to this initial message, individuals in the treatment arm will receive the following intervention components, developed based on recent evidence regarding behavioral science approaches to activating health behaviors: Targeted messages about the importance and benefits of primary care Default scheduling into a primary care appointment at approximately 3-4 months after delivery Reminders about the appointment and importance of follow up primary care at 2-4 points during the postpartum period via the patient portal Tailored language in the reminders based on recent evidence from behavioral science about the most effective approaches to increasing take-up. For example, messages will inform the patient that an appointment is being held for them at their doctor. Salient labeling on follow-up appointments Direct PCP messaging about the scheduled follow-up

Hypertension, Hypertension in Pregnancy, Diabetes Mellitus, Gestational Diabetes, Obesity, Depressive Disorder, Anxiety Disorders

Behavioral science informed interventions to assist in the transition from postpartum to primary care providers

Any visit with 1) a primary care provider (e.g., internal medicine, family medicine, pediatrics, gynecology) and 2) receipt of "annual" or "health care maintenance" services OR disease-specific management (diabetes, hypertension, obesity, mental health)

Any visit with 1) a primary care provider (e.g., internal medicine, family medicine, pediatrics, gynecology) and 2) receipt of "annual" or "health care maintenance" services OR disease-specific management (diabetes, hypertension, obesity, mental health)

Rate of visit with a patient's assigned primary care provider for receipt of "annual" or "health care maintenance" services OR disease-specific management (diabetes, hypertension, obesity, mental health)

Rate of visit with a patient's assigned primary care provider for receipt of "annual" or "health care maintenance" services OR disease-specific management (diabetes, hypertension, obesity, mental health)

Rate of blood pressure measurement documented in the health record among those with or at risk for hypertension

Blood pressure documented in the EHR among those diagnosed within chronic or pregnancy-related hypertension

Rate of blood pressure measurement documented in the health record among those with or at risk for hypertension

Blood pressure documented in the EHR among those diagnosed within chronic or pregnancy-related hypertension

Clinical support services (e.g., social work, psychiatry, therapy) for individuals with mood or anxiety disorders

Clinical support services (e.g., social work, psychiatry, therapy) for individuals with mood or anxiety disorders

New or continued oral or subcutaneous diabetes medication use control among individuals with diabetes

New or continued oral or subcutaneous diabetes medication use control among individuals with diabetes

Inclusion Criteria: Estimated date of delivery and the following 4-month postpartum outcome assessment window completed prior to study end date Currently pregnant or within 2 weeks of delivery Have one or more of the following conditions: 1) Chronic hypertension, 2) Hypertensive disorders of pregnancy or risk factors for hypertensive disorders of pregnancy per the USPSTF aspirin prescribing guidelines (e.g., history of pre-eclampsia, kidney disease, multiple gestation, autoimmune disease), 3) Type 1 or 2 diabetes, 4) Gestational diabetes, 5) Obesity (pre-pregnancy body mass index ≥30 kg/m2), 6) Depression or anxiety disorder Have a primary care provider listed in the electronic health record (EHR) Receive obstetric care at the study institution's outpatient prenatal clinic Have access to and be enrolled in the EHR patient portal and consents to be contacted via these modalities Able to read/speak English or Spanish language Age ≥18 years old Not actively known to have or undergoing work-up for fetal demise Exclusion Criteria: No primary care provider listed in the EHR Primary language other than English or Spanish No access to online patient EHR portal