Latest / Becker’s Healthcare - Clinical Leadership Podcast / Melissa Hasler, APRN, CNM, Director of Certified Nurse Midwifery at Fairview Health Services

Transcript

Melissa Hasler, APRN, CNM, Director of Certified Nurse Midwifery at Fairview Health Services · Becker’s Healthcare - Clinical Leadership Podcast

• 0:00
  This is Rosie Talaga with the Becker's Healthcare
• 0:02
  podcast.
• 0:03
  I'm thrilled today to be joined by Melissa
• 0:05
  Hassler, director of certified nurse midwifery at Fairview
• 0:09
  Health Services.
• 0:10
  Melissa, it's a pleasure to have you on
• 0:11
  the podcast today.
• 0:13
  Thanks, Rosie. Glad to be here. We have
• 0:15
  a super important and interesting conversation in store
• 0:18
  where we're gonna dive into black maternal health
• 0:21
  crisis, what's driving disparities in care, and how
• 0:24
  mHealth Fairview is working to create more equitable
• 0:27
  outcomes for all patients.
• 0:29
  Before we get into it, Melissa, can you
• 0:30
  please introduce yourself and just tell us a
• 0:32
  bit about your background?
• 0:34
  Sure. Absolutely.
• 0:35
  So I'm, Melissa Hassler. I'm a certified nurse
• 0:38
  midwife. I've been in practice for twenty one
• 0:40
  years now,
• 0:41
  and I actually have been in practice at
• 0:44
  Fairview that whole time. So I,
• 0:47
  have had a really wonderful experience with the
• 0:49
  health care system and had the opportunity to
• 0:51
  really get to know some of the really
• 0:53
  wonderful things that that system is doing in
• 0:55
  our state of Minnesota. So,
• 0:57
  I am in full clinical practice,
• 0:59
  and also have an administrative role. So get
• 1:02
  the opportunity
• 1:03
  to really,
• 1:04
  tie together what happens in clinical practice and
• 1:07
  what we're actually doing within our health care
• 1:09
  system to support optimal outcomes,
• 1:12
  specifically for
• 1:13
  pregnant people and
• 1:15
  birthing people in our state.
• 1:19
  That's wonderful. Thank you so much for the
• 1:20
  introduction.
• 1:21
  It's, particularly important and interesting that you have
• 1:25
  both the clinical practice side and the administrative
• 1:28
  role to really, like you said, tie the
• 1:30
  two together.
• 1:31
  Yeah. Exactly.
• 1:32
  It's really you know, it's one thing to
• 1:35
  sort of hear,
• 1:37
  talking points about what is happening in maternal
• 1:40
  health, but to be able to actually experience
• 1:42
  it both with the patients and also the
• 1:45
  providers,
• 1:46
  the obstetricians and the midwives that I support
• 1:48
  within our system, really figuring out what are
• 1:51
  we doing, and are we doing the best
• 1:53
  we can, and how can we structure our
• 1:54
  system
• 1:55
  to actually support and improve
• 1:57
  maternal health. There is absolutely no question we
• 2:00
  have a maternal health crisis in our entire
• 2:02
  nation. It is a problem,
• 2:04
  and it has been sort of there's been
• 2:06
  a rising
• 2:08
  swell of awareness,
• 2:10
  particularly over the past five years. But now
• 2:12
  we're really at a point where
• 2:14
  we see it. We know it's there. What
• 2:16
  are we gonna do about it? And how
• 2:18
  do we, within our health care
• 2:20
  system, structure our tools and our resources to
• 2:23
  help try and make an impact in that,
• 2:25
  maternal health
• 2:26
  crisis?
• 2:28
  That's really powerful. Thank you. And I'd like
• 2:31
  to talk more about that crisis.
• 2:33
  Such an important call out, especially coming off
• 2:36
  the heels
• 2:36
  of black maternal health week, which is an
• 2:39
  important moment for reflection and in the community.
• 2:42
  First, what is the black maternal health crisis
• 2:44
  in The US, and what factors are contributing
• 2:47
  to this?
• 2:49
  So in 2023,
• 2:50
  the maternal mortality rate in The US overall
• 2:53
  was about eighteen point six deaths per 100,000
• 2:57
  live births.
• 2:58
  That's quite high, particularly for a developed nation.
• 3:02
  And then when we break it down further,
• 3:04
  people who identify as black, that mortality rate
• 3:07
  is even higher. It's fifty point three deaths
• 3:10
  per 100,000
• 3:11
  live births in 2023.
• 3:13
  That's more than double the national rate.
• 3:17
  That is
• 3:18
  a problem.
• 3:19
  That is a stark reminder
• 3:22
  that we are not actually getting to the
• 3:24
  root of the problem of
• 3:27
  maternal mortality
• 3:28
  and then also identifying the fact that there
• 3:31
  have to be some factors that are contributing
• 3:34
  to that,
• 3:35
  increasing rates and very high rate for particularly
• 3:39
  black and brown birthing people.
• 3:41
  Absolutely. That is, like you said, a tragic
• 3:45
  tragic crisis that the black maternal mortality rate
• 3:48
  will be more than double the national rate.
• 3:50
  And like you said, that that does mean
• 3:52
  that there are factors contributing to this. This
• 3:54
  doesn't just happen naturally. So like I was
• 3:57
  saying, what are some of those factors that
• 3:59
  you,
• 4:01
  think are some of the highest causes for
• 4:03
  this?
• 4:04
  So there are a lot it's a very
• 4:06
  complex and complicated
• 4:09
  problem.
• 4:10
  But, really, what we've identified,
• 4:13
  particularly within our system, having an opportunity to
• 4:16
  reflect and see what is happening and really
• 4:19
  look at evidence based care and literature
• 4:21
  and evidence from our public health researchers and
• 4:24
  from our,
• 4:26
  clinical researchers and more,
• 4:28
  maternal care,
• 4:29
  looking at what is the evidence showing us.
• 4:32
  And what we do know for a fact
• 4:34
  is that race is often used
• 4:36
  as a proxy
• 4:37
  for biologic or genetic differences.
• 4:40
  And we know that race is actually
• 4:42
  not that. It's a social and societal construct
• 4:45
  that cannot be used as a proxy for
• 4:48
  biologic differences. So when we use race to
• 4:51
  determine a risk factor, we're really eliminating
• 4:54
  or over identifying people who are at risk
• 4:57
  for adverse income outcomes.
• 4:59
  So when we filter things inappropriately,
• 5:01
  that really changes the course of care for
• 5:04
  the pregnant person.
• 5:05
  And when that happens, we miss opportunities to
• 5:07
  intervene when we can.
• 5:09
  And it also obscures the true underlying cause
• 5:12
  of the adverse pregnancy outcomes, such as systemic
• 5:15
  racism.
• 5:16
  There are socioeconomic
• 5:17
  factors that play into this.
• 5:19
  And all of this really just exacerbates the
• 5:21
  health disparities by misattributing
• 5:23
  risk factors and failing to address the really
• 5:26
  true underlying causes
• 5:27
  that lead to these adverse outcomes.
• 5:30
  I can give you a couple of examples
• 5:32
  of, you know, things that we've done in
• 5:34
  our system
• 5:35
  that we are trying to sort of target
• 5:38
  the why
• 5:39
  of the outcomes that we're seeing.
• 5:42
  One thing we're able to do is in
• 5:45
  2023,
• 5:47
  we created,
• 5:48
  internally a birth justice initiative
• 5:51
  that was a cross,
• 5:53
  system
• 5:54
  sort of collaborative
• 5:55
  of all sorts of different people and employees
• 5:59
  to talk about and really explore
• 6:02
  what are the issues that are impacting this
• 6:04
  maternal mortality
• 6:05
  and how can we bring,
• 6:08
  justice and,
• 6:10
  you know, appropriate care for everybody that we
• 6:13
  care for. So in this birth justice initiative,
• 6:17
  we also were able to align looking at
• 6:20
  our
• 6:21
  systematic
• 6:22
  prenatal care that's provided to all pregnant people
• 6:24
  in our system and figure out what can
• 6:27
  we look at in that care provision
• 6:30
  that may be causing or perpetuating some of
• 6:33
  these adverse outcomes
• 6:34
  particularly
• 6:35
  related to race.
• 6:37
  So using
• 6:38
  both the birth justice initiative and all also
• 6:41
  our internal system and drive and commitment to
• 6:45
  our community
• 6:46
  and to equitable care,
• 6:49
  using those two powers
• 6:51
  to look at our own care and our
• 6:53
  care map is actually what we call it,
• 6:55
  which is the care map is sort of
• 6:57
  the process by which we,
• 6:59
  build our tools and provide care universally to
• 7:02
  all pregnant people within our system. So how
• 7:05
  do we use this birth justice initiative,
• 7:08
  our internal Fairview values and mission
• 7:11
  and focus on equity,
• 7:14
  and target that prenatal pregnancy and birth care
• 7:17
  to improve outcomes.
• 7:19
  And we found some opportunities,
• 7:21
  particularly with our screening tools that we were
• 7:24
  utilizing in pregnancy to determine
• 7:26
  how we,
• 7:28
  provide either additional care or different care for
• 7:31
  folks who have increased risks.
• 7:35
  And so a couple of strategies. We've looked
• 7:37
  at,
• 7:38
  genetic screening. We've looked at maternal serum screening,
• 7:42
  lead screening, preeclampsia
• 7:44
  screening, diabetes screening,
• 7:46
  all of these different aspects of care to
• 7:48
  determine
• 7:49
  what are we doing right and what can
• 7:52
  we how can we eliminate the race or,
• 7:55
  the social construct of race from that risk
• 7:58
  assessment and really get down to the biologic
• 8:00
  and physiologic factors
• 8:02
  that may contribute to an outcome.
• 8:04
  And so and in addition to that piece,
• 8:07
  we're we're reconstructing things internally, providing care differently
• 8:11
  for people universally, and also advocating
• 8:14
  nationally
• 8:15
  for other,
• 8:17
  laboratory
• 8:18
  places that we send off our samples to
• 8:21
  to also
• 8:22
  eliminate race based screening to really get down
• 8:24
  to the root of how we need to
• 8:26
  care for pregnant people,
• 8:29
  for better outcomes.
• 8:30
  So it's sort of an internal move and
• 8:32
  then also a national move to try and
• 8:34
  make some change with this.
• 8:36
  Absolutely. And there's so much importance in what
• 8:39
  you just said, especially,
• 8:40
  I think, that call out for race being
• 8:43
  used often as a proxy, but it really
• 8:45
  being a social construct and getting back and
• 8:47
  getting down to those real biological
• 8:49
  factors.
• 8:51
  It's really nice to also hear about that
• 8:54
  birth justice initiative and,
• 8:56
  Fairview's internal drive and commitment. I particularly like
• 8:59
  how you called those your two powers, your
• 9:01
  drive and commitment to your mission.
• 9:03
  Yep. I'd like to hear with that context
• 9:05
  in mind a little more about how this
• 9:07
  issue
• 9:08
  kind of initially resonated with your organization, how
• 9:11
  it still is. So what motivated Fairview to
• 9:14
  address racial and ethnic disparities in maternal care?
• 9:19
  So, couple of years ago, I think it
• 9:21
  was 2022
• 9:22
  and the beginning of 2023,
• 9:24
  our organization
• 9:26
  just really made a focused intentional
• 9:29
  call out of bringing equity to all health
• 9:32
  care.
• 9:33
  And a part of that was intentionally
• 9:36
  evaluating
• 9:37
  all of our care maps,
• 9:39
  so our packages of care,
• 9:41
  evaluating them from a lens of equity
• 9:44
  and making sure that we are addressing
• 9:46
  every aspect that potentially
• 9:49
  could lead to
• 9:50
  inequity in outcomes
• 9:52
  or inequity in care.
• 9:54
  And that intentionality
• 9:56
  really,
• 9:57
  you know, the system provides resources and incredible
• 10:01
  people within our system who are subject matter
• 10:04
  experts on equity,
• 10:06
  within health care, particularly.
• 10:08
  Those resources
• 10:09
  helped,
• 10:11
  inform
• 10:12
  our new care map. And so that kind
• 10:14
  of it was a synergy between this really
• 10:17
  internal focus from Fairview on equity,
• 10:20
  the birth justice initiative,
• 10:22
  and then also kind of that national spotlight
• 10:24
  on what's happening with maternal morbidity and mortality.
• 10:29
  And it just came together
• 10:30
  really
• 10:31
  nicely in the end of twenty twenty three,
• 10:34
  that allowed us to really dig into this
• 10:37
  prenatal care map and and make sure you
• 10:39
  know, it was a call to action from
• 10:41
  our,
• 10:42
  internal
• 10:43
  employees and also
• 10:45
  our organization to say, what are we doing
• 10:48
  for maternal health care? And this was our
• 10:50
  answer. It was to break down our prenatal
• 10:53
  care process
• 10:54
  and rebuild it in a way that was
• 10:56
  really central to
• 10:58
  equity and care, but also equitable outcomes.
• 11:02
  And figuring out how do we provide that
• 11:04
  care within the pregnancy journey
• 11:07
  that leads to that equitable outcome.
• 11:09
  And it's different from standardizing care. We're not
• 11:11
  standardizing things across the board. I mean, in
• 11:14
  a sense, we are. We are providing,
• 11:17
  the highest evidence based care we can to
• 11:20
  every single person that steps through the door
• 11:22
  that's pregnant,
• 11:24
  but also understanding that within that care, we
• 11:26
  need to individualize it to meet the end
• 11:30
  goal
• 11:30
  of equitable
• 11:32
  outcomes. Right? So what's great for one person
• 11:35
  in the beginning might not be great for
• 11:37
  everybody. And so how do we build a
• 11:39
  system
• 11:39
  that takes that into consideration
• 11:41
  that lands us with the equitable outcomes and
• 11:44
  improved maternal and fetal outcomes at the end.
• 11:48
  Totally. I think that's a great call out
• 11:50
  too about it's not exactly standardization. I think
• 11:53
  that goes back to the difference just between
• 11:56
  equality
• 11:57
  being equal or being equitable. You know, standardization
• 11:59
  might be the same across the board, equal
• 12:01
  across the board, whereas your intentional,
• 12:05
  lens of equity for your care maps is
• 12:07
  more of that
• 12:08
  equitable,
• 12:09
  way of looking at things. Exactly.
• 12:12
  I know you did mention,
• 12:14
  specific steps that your organization is taking to
• 12:17
  confront this bias such as the birth justice
• 12:20
  initiative. I was hoping you could either talk
• 12:22
  about other strategies or go in more to
• 12:25
  depth for the birth justice initiative
• 12:27
  that you're implementing to reduce this bias in
• 12:29
  pregnancy and delivery care?
• 12:32
  Absolutely. I've got a couple of examples I'd
• 12:34
  like to focus on.
• 12:36
  One first example is
• 12:39
  our screening for preeclampsia risk in pregnancy.
• 12:42
  Preeclampsia
• 12:43
  is is a condition that's unique to pregnancy,
• 12:46
  and postpartum that results in high blood pressure
• 12:48
  and then end organ damage that can be
• 12:51
  potentially fatal for some people,
• 12:54
  and have long term effects on the pregnant
• 12:56
  person and for the fetus.
• 12:58
  And previously,
• 12:59
  our screening for identifying people who are at
• 13:02
  risk for this utilized,
• 13:04
  things such as,
• 13:05
  identifying
• 13:11
  risk factor for developing
• 13:13
  preeclampsia.
• 13:14
  We know now that that actually is not
• 13:17
  a specific
• 13:19
  risk factor for developing preeclampsia.
• 13:21
  What we wanna focus on is
• 13:24
  the pieces of the
• 13:26
  biology,
• 13:28
  the pieces of the genetics,
• 13:30
  and the conditions of the body that would
• 13:32
  lead to preeclampsia.
• 13:46
  Hypertension
• 13:47
  disorders of pregnancy, a history of diabetes,
• 13:50
  multifetal gestation, or, you know, multiple
• 13:53
  fetuses,
• 13:54
  twins, triplets, and so on,
• 13:57
  kidney disease and autoimmune disease.
• 13:59
  So those are examples of specific
• 14:02
  conditions that would lead someone to
• 14:05
  have preeclampsia potentially be at risk for preeclampsia.
• 14:08
  And by identifying those, we can then take
• 14:10
  interventions that help decrease those risks throughout the
• 14:13
  pregnancy.
• 14:15
  Another example is gestational diabetes screening.
• 14:18
  Previously, we utilized,
• 14:21
  screening high risk qualifiers as people who identified
• 14:24
  as African American,
• 14:26
  Latino,
• 14:27
  Native American,
• 14:28
  Asian,
• 14:29
  Pacific Islander.
• 14:31
  We know now that that race based screening
• 14:34
  is actually not comprehensive
• 14:36
  enough and is not accurately reflecting the folks
• 14:39
  who are at risk for gestational diabetes.
• 14:41
  So now we've pivoted to a universal
• 14:44
  hemoglobin a one c testing, which is,
• 14:47
  everyone who's pregnant and enters care in our
• 14:50
  system will receive that blood work
• 14:52
  that tells us their stratifies their risk for
• 14:55
  developing diabetes.
• 14:57
  So really
• 14:58
  moving away from
• 15:00
  those social constructs of race
• 15:03
  and pivoting to the actual biologic and physiologic
• 15:06
  factors that would play into increasing those risk
• 15:09
  factors.
• 15:10
  But it doesn't end there. It's not enough
• 15:13
  to just eliminate race and screen for everything
• 15:16
  else because we know the root of the
• 15:18
  problem
• 15:19
  is deeper than that.
• 15:21
  So we have added screenings.
• 15:23
  We've added social determinants of health screenings.
• 15:27
  We have added screening for transportation
• 15:30
  barriers.
• 15:31
  We've added,
• 15:33
  screening for food insecurity,
• 15:35
  housing stability.
• 15:37
  Those are pieces that we know actually
• 15:40
  influence
• 15:41
  and contribute
• 15:43
  to maternal outcomes that are negative.
• 15:45
  So not only are we identifying
• 15:48
  those risks from social determinants of health aspect,
• 15:51
  but then also creating wraparound services and access
• 15:54
  to resources
• 15:55
  that help intervene in those social determinants that
• 15:59
  can impact that pregnancy.
• 16:01
  Absolutely.
• 16:02
  That's really important again to go back to
• 16:04
  that idea of moving away from the social
• 16:07
  constructs of within the screening processes and risk
• 16:10
  identifying processes.
• 16:12
  I'd like to dive into that a little
• 16:13
  bit deeper,
• 16:15
  and have you talk about how these race
• 16:17
  based screenings and calculations
• 16:19
  negatively impact care and outcomes.
• 16:23
  Yeah. So so when we
• 16:25
  eat there's a couple of different ways. Number
• 16:27
  one, it's if you focus on the race
• 16:30
  based screening, you miss an opportunity for interventions
• 16:34
  for folks
• 16:35
  who
• 16:36
  may not have self identified as a specific
• 16:38
  race. For example,
• 16:40
  many of us,
• 16:42
  have many different ethnic backgrounds,
• 16:46
  and many of us don't actually know what
• 16:48
  our specific
• 16:50
  ethnic or, you know, specific genetic risk factors
• 16:53
  are. And so if we don't know to
• 16:56
  identify ourselves as a specific
• 16:58
  race or or count ourselves in that specific
• 17:01
  race, it really is not capturing anyone who
• 17:03
  potentially could be at risk.
• 17:05
  In addition,
• 17:06
  it obscures the true underlying cause of the
• 17:10
  adverse pregnancy outcomes, like racism
• 17:13
  within
• 17:14
  the health care system or socioeconomic
• 17:16
  factors.
• 17:18
  And then it just also
• 17:19
  exacerbates the health disparities
• 17:21
  by misattributing
• 17:23
  risk factors
• 17:24
  And then again, not addressing those true underlying
• 17:27
  causes, which which we think are more likely
• 17:30
  related to
• 17:32
  socioeconomic
• 17:33
  and social
• 17:34
  constructs versus
• 17:36
  actual biologic,
• 17:38
  contributing factors for the outcome.
• 17:41
  So it can really impact both missing people
• 17:44
  and
• 17:45
  actually adding people to,
• 17:48
  a risk based profile that is actually misattributing
• 17:52
  their risk,
• 17:53
  and that can can really
• 17:56
  change the course of their care and hinder
• 17:58
  and in addition, hinder efforts to address the
• 18:01
  root cause of what's really
• 18:03
  the reason for the health disparity.
• 18:05
  Absolutely. It is so important
• 18:08
  to really be focusing on the root cause,
• 18:10
  and I think that that's a really powerful
• 18:12
  note
• 18:13
  to say that, you know, patients maybe can't
• 18:16
  put themselves into a box or quite literally
• 18:18
  check a box that they identify with one,
• 18:21
  self identify with one particular race because, you
• 18:24
  know, as
• 18:25
  as time progresses, that's just getting trickier and
• 18:28
  trickier for everyone. So
• 18:30
  zooming out a bit for our last question,
• 18:32
  I'd like to connect this maternal care work
• 18:34
  to the broader organization. So I'm wondering how
• 18:38
  this initiative and this mission
• 18:41
  aligns with the organization's
• 18:42
  broader commitment
• 18:43
  to health equity.
• 18:45
  This is a great question and something I'm
• 18:47
  really passionate about because I
• 18:50
  I have stayed in this organization for a
• 18:52
  long time for a reason and continue
• 18:55
  to choose to stay here because
• 18:57
  of the focus on
• 19:00
  patient centered care
• 19:02
  that evolves from dignity
• 19:05
  and respect,
• 19:06
  but also providing
• 19:08
  the highest quality of care we can. And
• 19:11
  it doesn't happen
• 19:12
  alone. It happens within our communities.
• 19:15
  And our our Fairview Health System is really
• 19:18
  focused on not just
• 19:20
  caring for the people within the doors of
• 19:22
  our health care facilities,
• 19:24
  but the community in which we live. We
• 19:26
  do not just
• 19:28
  aim to keep people,
• 19:31
  to fix people's pathology. Right? We aim to
• 19:34
  really provide whole person care that keeps people
• 19:38
  out of our facilities
• 19:39
  and promotes health and well-being within the community.
• 19:42
  So making sure that we are
• 19:45
  really looking at how we provide that care,
• 19:47
  pulling the customer, the consumer, or the patient
• 19:50
  into that process,
• 19:52
  and better understanding
• 19:53
  how we can do that within the walls
• 19:55
  of our hospital and also within our community.
• 19:58
  So we have a lot of initiatives related
• 20:02
  to community advancement
• 20:03
  and, ensuring that the voice of the the
• 20:06
  community member and the customer is a part
• 20:08
  of the care that we build and provide,
• 20:10
  but also internally really changing
• 20:13
  the barriers, the systemic barriers that we've been
• 20:16
  seeing historically in health care.
• 20:18
  We can't do it overnight. It's a huge,
• 20:21
  long
• 20:22
  initiative that we are so committed to and
• 20:25
  continue to commit to
• 20:26
  year after year after year because that we
• 20:29
  know that when we keep our patients healthy,
• 20:31
  we keep our communities healthy. And particularly with
• 20:35
  pregnancy,
• 20:36
  pregnant people
• 20:38
  have babies. Right? And these babies are members
• 20:41
  of our community, and those babies
• 20:43
  grow up in these communities and become adults.
• 20:45
  And the more we can provide
• 20:47
  health and well-being at the root of that,
• 20:51
  the healthier communities are, the healthier our state
• 20:54
  is. And hopefully,
• 20:55
  you know, we can have a national impact.
• 20:58
  But we've gotta start somewhere. And Fairview has
• 21:01
  really driven home a commitment
• 21:03
  of health equity
• 21:04
  and getting to the root cause and making
• 21:07
  sure that what we're doing
• 21:09
  is, you know, again,
• 21:10
  from from the patient centered aspect of dignity,
• 21:14
  respect, and highest quality of care.
• 21:17
  That's a great point. I love the idea
• 21:19
  of, you know, you have to start somewhere.
• 21:21
  Where's the root cause and what better place
• 21:23
  to start than maternal care where these Right.
• 21:26
  Humans are entering the world. I mean, talking
• 21:28
  about whole person care.
• 21:30
  That's great. And it's so great to hear
• 21:32
  your passion for this mission that is so
• 21:35
  clearly a big part of Fairview's purpose.
• 21:37
  Absolutely.
• 21:38
  Yep.
• 21:39
  Well, thank you so much, Melissa. That is
• 21:41
  all the time we have for today, but
• 21:42
  it's been an absolute pleasure,
• 21:45
  hearing your insights about all the important work
• 21:47
  happening at Fairview.
• 21:48
  These conversations are truly vital as we work
• 21:51
  towards a more equitable maternal care. So it
• 21:54
  has been a pleasure,
• 21:55
  and thank you all for listening.
• 21:57
  Thank you, Rosie.