Spotlight on Social Determinants of Health

This week’s Patient Experience Virtual Summit put a spotlight on disparities in care and what can be done to address them. The keynote speaker was Alisahah Cole, MD, System Vice President, Population Health Innovation and Policy at CommonSpirit Health. In her talk she encouraged healthcare providers to remove “non-compliance” from their vocabulary and instead think in terms of reducing barriers to care. She emphasized that when patients don’t adhere to a care plan, it’s not because they don’t want to be healthy. The key is uncovering those barriers and helping patients address them with support services they really need.

How Remote Monitoring Can Reduce Health Inequities

Another session titled, “How Remote Monitoring Improves Access To Care, Reduces Health Inequities” touched on some similar themes. Matthew K. Hoffman, MD, MPH, who leads Obstetrics and Gynecology at ChristianaCare, shared how his organization is leveraging a combination of tools to eliminate health inequities for his patients.

Many women in Delaware, where Dr. Hoffman practices, face poverty, racial disparities, and rising rates of obesity and other chronic conditions. There is also a clear need to reduce racial disparities and improve postpartum care after new mothers are sent home:

  • The maternal mortality in the United States is increasing, but there is a shift in the timing of its occurrence from the hospital to the postpartum period
  • Black maternal mortality ratio is 3.2x the white rate
  • 82% of deaths in the postpartum period are related to hypertension
  • ACOG recommends blood pressure checks between postpartum days 5 to10 for women with hypertensive disorders of pregnancy, but only 30% of women return to the office for a visit

Webinar: Remote Monitoring Reduces Health Inequities

ChristianaCare’s Matthew Hoffman, MD, MPH, FACOG presents the clinical challenges among postpartum women and his research-based strategies to close gaps in healthcare disparities for women in disadvantaged communities.

Reducing Barriers to Care with Accessible Technology

ChristianaCare wanted to find a way to incorporate remote monitoring to get women the care they need and reduce these negative trends. While technology is sometimes viewed as an additional barrier for disadvantaged communities, Dr. Hoffman noted that 92% of women of childbearing age have smartphones and are often likely to use pregnancy apps.

So, using a combination of their homegrown app, Pregnancy Care Coach, and Twistle’s secure texting platform, ChristianaCare is making significant advances to improve care. Pregnancy Care Coach provides medical information, local resources, and connects women to support services throughout pregnancy. Twistle, a simple SMS text-based communication platform, keeps women connected to their care team and prompts them to provide important health data so the care team can intervene if needed.

So far ChristianaCare is addressing several important areas where added support is needed with remote monitoring:

They have seen remarkable results including a 55% decrease in 30-day hospital readmissions and increased detection of type 2 diabetes by 213% among postpartum women. Dr. Hoffman noted that after offering text-based communication, “We learned that by providing radical convenience, we could meaningfully move the needle.” When asked why he uses a tool outside ChristianaCare’s EHR, he noted that each person’s journey is unique and so it’s important to have a flexible tool that allows for quick development for new use cases and adjustments of existing ones.

If you need help optimizing and personalizing patient care pathways, contact Twistle at