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Expanding care management to Camden moms with Camden Delivers

October 3, 2016
A group of Camden moms and babies pose together

Our Camden Delivers initiatives apply our expertise in care coordination to women of childbearing age who have complex health and social needs. We know that chronic illness can increase the risk of maternal and infant mortality, but many women in Camden are dealing with pregnancy and motherhood as well as housing instability, lack of income, lack of support structure, poor mental health, domestic violence, addiction, and more. With so much going on, managing chronic health conditions is often the last thing on their minds. Camden Delivers connects women to the services they need to meet their immediate needs and better manage their health long-term.

Tanya* is a Camden Delivers patient who was diagnosed with HIV during pregnancy. Soon after she learned that she was HIV-positive, her case was referred to Child Protective Services (CPS). Tanya did not have a place of her own and was ‘doubling up’ with a friend in public housing. Fearing eviction, her friend told her she had to leave.

Tanya was about to deliver her baby and become homeless at the same time. With CPS already involved, she was certain that she would lose custody of her child.

We were alerted to Tanya’s situation through the Perinatal Risk Assessment data that we access through our Health Information Exchange for all pregnant women in our Medicaid Accountable Care Organiztion (ACO). When we see a high-risk patient like Tanya, we make an engagement attempt at the hospital or in the community. A Coalition Community Health Worker (CHW) met Tanya in the neonatal intensive care unit (NICU), where she was learning to administer medication to her HIV-positive infant. The two quickly formed a relationship and the CHW worked with Tanya to get her documentation together for housing and employment.

Today, Tanya still has custody of her child and we are helping her work consistently with her CPS caseworker. To help her proactively manage her health, Tanya and her baby are enrolled in a program in Camden that offers medical care, case management, and behavioral healthcare for people living with HIV.

Tanya has a long road ahead, but for her, pregnancy was a catalytic moment for change. The relationship she formed with her Camden Coalition CHW encouraged her to prioritize her own health as part of her goal to be a good mom. In a short amount of time, she has learned how to stay linked to her healthcare providers, social services providers, and caseworker, and she has learned how to advocate for herself.

Through Camden Delivers, which is supported by funding from Merck, through Merck for Mothers, we work intensively with women like Tanya who have complex health and social needs, and we also work on a larger scale in the city of Camden. We have found that OB/GYN and primary care practices often don’t talk to each other, and women’s health suffers as a result. That’s why we work to connect all women of childbearing age in the Camden Coalition ACO to OB care during pregnancy and to primary care after pregnancy to make sure their chronic conditions are addressed and that they receive the care they need.

In our role as care coordinators, we are enhancing the continuity of care for women in this city and are ensuring a healthier city for this generation and the next.

 

*Name and identifying details of this story have been changed.

This program is supported by funding from Merck, through Merck for Mothers, the company’s 10-year, $500 million initiative to help create a world where no woman dies giving life. Merck for Mothers is known as MSD for Mothers outside the United States and Canada.

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