A care coordination system centered on Black women and birthing persons to reduce Black infant mortality

The Dane County Health Council (DCHC) and The Foundation for Black Women’s Wellness (the Foundation) today announced a major step forward in local efforts to improve health outcomes for Black women, birthing persons and babies.

ConnectRx Wisconsin is a new care coordination system supporting Black pregnant women and birthing persons to gain greater access to healthcare and family-stabilizing resources that fill potentially unmet social needs such as food, financial assistance, housing, employment and transportation. It is designed to reduce the occurrence of low birthweight and improve birth outcomes for Black women, birthing persons and babies in Dane County. 

The system launch was led by DCHC, the Foundation, its project partner EQT By Design and several other key partners. ConnectRx is powered by tools developed by Verona, Wisconsin-based healthcare software giant, Epic Systems. It includes a screening process used by several Dane County health systems to identify both medical and non-medical needs of patients, a community-based workforce dedicated to connecting patients with local resources and a shared care coordination and referral technology.

“ConnectRx is a critical milestone in the ongoing work we are doing to advance the health and well-being of Black women, birthing people, babies and families in Dane County,” said Lisa Peyton-Caire, CEO and president of The Foundation for Black Women’s Wellness. “What’s most powerful about the system is its emergence from the collaboration of health systems, Black women and the community working together to eliminate racial birth disparities and save the lives of Black babies.”  

The new system stems from more than four years of data gathering, partnership and community engagement. In 2017, the results from community health needs assessments confirmed maternal and child health to be one of the most persistent local health concerns. The DCHC used this data to generate new approaches to its longstanding work on eliminating disparities in low weight births between Black and white women in Dane County.

Notably, Wisconsin has one of the highest Black infant mortality rates in the United States, significant disparities in household income and was cited as the only state in the country where the life expectancy gap is widening between Black and white women.

In 2018, DCHC commissioned the Foundation and EQT By Design to conduct a community engagement effort that specifically centered Black women and community members to weigh in on the issue. Over a nine-month period, they engaged more than 300 Black community members and service providers across Dane County to identify root causes of these disparities as well as solutions to improve Black birth outcomes in the county.

These efforts culminated in the groundbreaking Saving Our Babies Report, which pointed to stress caused by economic insecurity, racism and bias in the daily experiences of Black women and families, as well as disconnected and difficult-to-navigate community health services. The report, which includes community-based and system-level recommendations, led to the launch of the formal Saving Our Babies Initiative in 2019, the Black Maternal and Child Health Alliance of Dane County (the Alliance) in 2020 and paved the way for ConnectRx.

“This work requires a deep dedication to partnership and listening to the voices of the experts and the community members, then acting on what we hear with tangible, systemic change,” said Dr. Tiffany Green, assistant professor of population health sciences and obstetrics and gynecology at the UW School of Medicine and Public Health, and co-chair of the Alliance.

ConnectRx begins with a universal screening for social determinants of health in healthcare appointment settings. A culturally inclusive workforce that includes doulas, community health workers and community health promoters, will work directly with patients to meet their needs. UW Health is serving as the ConnectRx host site, which includes employing the community health workers and providing Epic care coordination tools to all health system and community-based partners.

Black pregnant women and birthing patients with identified support needs are referred by their care team to community health workers who will connect them with trusted community agencies to gain access to resources like housing and employment assistance and mental health services. Patients with the highest levels of health risk will also be offered the support of doulas, coordinated by the Foundation, for additional support throughout their pregnancy journey in an effort to reduce complications and support postpartum health.

ConnectRx uniquely integrates healthcare and social service systems within a care coordination technology solution. A secure referral system connects a patient’s secure electronic health records to United Way of Dane County’s 211 community resources, facilitating actionable referrals and follow-up mechanisms to help Dane County families increase their income and improve health outcomes.

All DCHC health system partners – Access Community Health Centers, Group Health Cooperative of South Central Wisconsin, SSM Health, UnityPoint Health – Meriter and UW Health – are invested in ConnectRx, have implemented the tool and will facilitate referrals and follow-ups with their patients.

“We as health systems have a responsibility to address racial inequity with systemic change,” said Dr. Ken Loving, CEO, Access Community Health Centers. “With the potential to reach 200,000 households, 95% of patients and 99.6% of births in the county, ConnectRx can do just that, ultimately reducing racial disparities and improving health outcomes.”

Through the collective efforts of the DCHC and the Foundation, ConnectRx has secured $6 million dollars to date to support the effort including $1 million from Schmidt Futures, $1 million from the Wisconsin Partnership Program, $1 million from the Wisconsin Department of Administration in America Rescue Plan Act funding and an additional $3 million in congressionally directed spending support.

“ConnectRx will transform how we identify and enact sustainable solutions to improve birth outcomes,” said Ariel Robbins, program director, DCHC. “The Dane County Health Council is proud to facilitate the work that has stemmed from the voices of our community members to change the health trajectory of their lives and the lives of their children.”

The Dane County Health Council is a coalition of healthcare providers, government and nonprofits with a mission to eliminate gaps and barriers to optimal health and reduce disparities in health outcomes in Dane County. Council members include Access Community Health Centers, Black Maternal and Child Health Alliance, Group Health Cooperative of South Central Wisconsin, Madison Metropolitan School District, Public Health Madison & Dane County, SSM Health St. Mary’s Hospital, United Way of Dane County, UnityPoint Health – Meriter and UW Health. 

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