Opportunity

Preeclampsia is a pregnancy disorder characterized by high blood pressure (hypertension) and increased urine protein levels. Blood pressure in patients with pregnancy-related hypertension can take as long as three months to normalize and is likely to spike in the first ten days after delivery, putting new moms at risk for stroke, seizures, and organ failure.  

In 2013, the American College of Obstetricians and Gynecologists (ACOG) issued guidelines to monitor postpartum blood pressure in this population at two points – once at 72 hours and again seven to 10 days after delivery.  

When ACOG released its recommendations, there was no guidance or best practice model for achieving the new standards. The standard of care at the Hospital of the University of Pennsylvania (HUP) required new moms to return to the office to have their blood pressure taken at the designated touchpoints. Show rates for these visits hovered at less than 50 percent, and hypertension was the leading cause of seven-day readmissions for obstetric patients at HUP in the two years after the recommendations were made.  

Despite numerous efforts to improve show rates – including increasing the availability of appointments and issuing phone and text reminders, practices did not meet ACOG guidelines. 

Intervention 

Heart Safe Motherhood (HSM) is a first-of-its-kind text-based postpartum blood pressure monitoring program. The program, which is administered and managed through Way to Health, enables patients to track their blood pressure from the comfort of their homes and communicate with their care team without visiting a doctor's office.   

Inpatient clinicians on labor and delivery and postpartum service identify and enroll at-risk women in the program based on eligibility criteria, including diagnoses and vital signs. From there, participants are given a digital blood pressure monitor for at-home use. Training on how to use the monitor and education about the program also occurs before discharge.  

Upon discharge, an automated blood pressure monitoring protocol is enacted. Patients are prompted twice daily via text message to take their blood pressure and share it with their care team. Patients with blood pressures within the normal range receive automated, real-time feedback based on a provider-determined algorithm. And when blood pressures are high enough to necessitate intervention, HSM pushes real-time alerts to providers so that, depending on the circumstances, they can reach out for more information, start or adjust medication, or triage patients to in-person care.  

Through automation and exception handling, HSM makes it possible for one provider to manage the blood pressures of an entire hospital's worth of enrolled deliveries in just a few hours a week. 

Impact 

HSM drives better maternal outcomes, improves patient experience, lessens the burden on care teams, and reduces the total cost of care for women with pregnancy-related and chronic hypertension in the immediate postpartum period.

In 2017, the team completed a randomized controlled trial comparing HSM to the usual care of office-based in-person blood pressure checks. HSM increased the clinic's ability to obtain blood pressure readings, with 92 percent of patients texting their blood pressure compared to 44 percent attending their office visit. And 80 percent of HSM patients met ACOG guidelines. During the study, approximately 15 to 20 percent of women had elevated blood pressure requiring medication initiation or adjustment. There were no readmissions among HSM participants, and women enrolled in the program were more likely to attend their postpartum visit, which is a valuable touchpoint to evaluate physical and mental well-being after delivery and support contraception planning and breastfeeding. At scale, postpartum hypertension readmission rates at HUP dropped from 5 percent before HSM to 1 percent, and hypertension was no longer the leading cause of seven-day obstetrical readmissions.  

A secondary analysis of the trial conducted by the HSM team found that the program eliminated the observed racial disparities in postpartum hypertension blood pressure ascertainment. Before the intervention, non-Black women were significantly more likely to attend an in-person blood pressure check than Black women, yet Black women were at higher risk of poor outcomes. With HSM, the team saw an increase in their ability to capture blood pressure for all patients, regardless of race. 

A further retrospective study based on insurance claims found that HSM participants were less likely to have adverse outcomes, had fewer postnatal ED visits and readmissions, and had more cardiology visits than comparison cohorts. These differences resulted in overall lower medical costs for HSM patients.

More than 23,000 patients received care through HSM as of April 2024.

HSM is the standard of care for obstetrics patients at HUP, Pennsylvania Hospital, Princeton Medical Center, Chester County Hospital, and Lancaster General Health. The team has also succeeded in spreading the program beyond Penn's walls with implementation at Jefferson Health, Einstein Health, Washington University in St. Louis, and Woman's Hospital in Georgia. Improved blood pressure ascertainment and reduction in hypertension-related readmissions have been observed at all HSM sites. 

Expansion to additional health systems is under exploration. The program is expected to launch at Georgia Memorial, the University of South Florida, and Alameda Health in the near future.