In New Jersey, only 74.8% of mothers began prenatal care in the first trimester from 2022-2024, and significant disparities in early and adequate prenatal care persist among women of color.

Over the course of multiple years, we monitored emergency department (ED) admissions through the Camden Coalition Health Information Exchange (HIE) and noticed that many pregnant individuals seen at South Jersey EDs did not appear to be connected to prenatal or other pregnancy-related care. In 2019 Camden was selected as one of ten initial cities for the Safer Childbirth Cities program, which gave us the opportunity to address this problem through collaboration with regional experts, data sharing, and flexible funding.

A proactive transition of care workflow

With the pilot program funding, we brought together seven partners – six prenatal care sites and one community-based maternal health organization – to test a proactive telephonic transition of care outreach model. Using the HIE, we identified individuals who were visiting one of 13 emergency departments in South Jersey with evidence of a current or recent pregnancy and no evidence of connection to pregnancy care. Partner sites conducted outreach to assist with appointment scheduling and connection to other resources. Learn more about the pilot phase of this workflow in our Pregnancy care initiation pilot demonstration snapshot.

Sustainability through partnership

When the pilot ended in 2023, our clinical partners shared that since there was no dedicated staff funding for outreach, they would be unable to sustain the workflow without the Camden Coalition’s backbone support because it was not critical to daily clinic operations. Fortunately, The Cooperative – the community-based maternal health organization – saw that the workflow complimented their existing work as a Connecting NJ (CNJ) site, which operates a county-based, single point-of-entry system for maternal and child health programs. Because of this, they leveraged their existing CNJ funds and staff to take on the prenatal care initiation workflow for their region.

Inspira, one of the original pilot sites, also saw the value for their region and introduced the program to Acenda Integrated Health, the Connecting NJ site for Cumberland, Gloucester and Salem counties, which are counties with a significant Inspira presence. Acenda enthusiastically agreed to take on the workflow with no additional funding. With just six months of support from the Camden Coalition, they launched the workflow, expanding this outreach to three additional counties.

Since the pilot launched, partners have:

• Outreached over 13,000 individuals
• Spoken with nearly 7,000 individuals
• Provided support to over 1,5000 pregnant individuals

The standard of care in New Jersey

In partnership with The Cooperative and Acenda, outreach is occurring for the prenatal care initiation program in all seven of the southern NJ counties – Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester and Salem.

Since the pilot’s end, the Camden Coalition has partnered with Family Health Initiatives (a subsidiary of The Cooperative) to complete an integration of the Camden Health Information Exchange (HIE) and CNJ Link, the Connecting NJ team’s primary documentation platform. This integration allows Connecting NJ staff to identify eligible individuals within their own system, and subsequently conduct outreach, make referrals, and document within one system.

These investments in the data infrastructure, as well as the State’s continued investment in Connecting NJ and the maternal health ecosystem in New Jersey, have forged a clear pathway to scale the prenatal care initiation program to the remaining 14 counties in New Jersey in partnership with other Connecting NJ programs.

Additionally, this outreach model offers the opportunity to identify and support high-risk pregnant and parenting populations who would benefit from more targeted outreach and support. The HIE allows the identification of subpopulations with clinical risk factors — such as hypertension, substance use disorders, and sexually transmitted infections – so that organizations with expertise and enhanced resources can develop customized outreach workflows that align with organizational goals and existing resources.

We are currently seeking funding to 1) support efforts to scale the prenatal care initiation program across the state, with the goal of establishing this proactive outreach model as the standard of care in New Jersey; and 2) pilot the application of this outreach model to support high-risk populations.

For more information, contact Erica Hartmann at [email protected]