Why It Matters
When new parents take their infants home from the hospital, they typically have many questions. Is my baby crying too much? Is she nursing enough? Does his poop look normal? During this challenging time, sometimes known as the “fourth trimester,” families need a great deal of support.
To meet this need, the Hospital of University of Pennsylvania (HUP), in partnership with Memora Health, developed a program called “Healing at Home”. The Hospital of the University of Pennsylvania is part of the Institute for Healthcare Improvement (IHI) Eliminating Inequities and Reducing Postpartum Morbidity and Mortality Learning Community. Participants focus on improving clinical and administrative processes to ensure safer and more equitable postpartum care and support for Black mothers and birthing persons.
The Healing at Home program consists of a virtual postpartum assistant, named Penny, which provides automated answers via text message to patients’ questions for the first six weeks after discharge. Penny also administers the Edinburgh Postnatal Depression Scale (EPDS) for screening, and provides blood pressure monitoring for low-risk patients. (High-risk patients participate in a program called Heart Safe Motherhood).
“We launched our program in March of 2020, when COVID-19 was starting when we saw a lot of our parents going home sooner rather than later,” said Laura Scalise, MSN, RN, Nurse Manager at HUP. “We wanted to make sure we could monitor our families that were leaving so soon [after childbirth], provide any connections to support (i.e., lactation referrals), and readily answer the questions they had.”
To develop the chatbot, the team enrolled 90 patients in a pilot program and instructed them to text any questions they had. Scalise and a group of her colleagues responded to these messages over a six-week period. They received over 2000 messages from these patients and found that many of the same questions came up repeatedly. “It was a lot of pee and poop questions and a lot of feeding questions,” said Scalise. This experience convinced them that they could create an automated system to respond to most of the questions as well as a process to escalate to a person if the computer couldn’t handle the scenario.
To develop the algorithm, the team fed the extensive packet of information already distributed to patients at discharge into the system. They conducted numerous Plan-Do-Study-Act (PDSA) cycles to improve performance. Scalise asked the virtual assistant questions a patient may ask (including difficult queries) and misspelled words to evaluate comprehension. “We were really hard on Penny when we were building out the system,” she said, “to assure accuracy thresholds were met.”
The virtual assistant is often able to provide a complete answer instantly, and Penny can also ask follow-up questions, if necessary. If a patient’s answers indicate the need for follow-up, an alert goes to the appropriate pediatrician, OB/GYN, or lactation consultant.
In addition to answering questions, Penny proactively reaches out to patients to provide certain information. These include postpartum warning signs (such as abnormal bleeding) and tips about caring for the baby’s umbilical cord. For low-risk patients who aren’t already monitored elsewhere, Penny also administers blood pressure checks (the program provides a blood pressure cuff for women as needed).
The virtual assistant also administers the EPDS at two weeks and six weeks. If a patient indicates they are feeling overwhelmed or that they need help, “Those alerts go me and the OB/GYN team,” said Scalise, “and we are able to triage appropriately.” Depending on the score, Penny will send the patient referrals for mental health resources, and — if the patient reports feeling suicidal — someone from their OB/GYN team will reach out to them. The system refers patients with high EPDS scores to their obstetrician, and Scalise reports that these patients are typically pleased to know that they will be getting a follow-up call from a physician. Urgent results (very high scores or thoughts of self-harm) are sent to the OB/GYN clinician via immediate text message.
To add a personalized touch, the team programmed Penny to refer to infants by name, and if patients need further care, the system automatically refers them to the correct obstetrician or pediatric provider and provides specific contact information. Currently, the program is available only in English, but the team will be piloting a Spanish version soon.
The program has had more than 1,680 patients enrolled to date, and the feedback from patients has been overwhelmingly positive. Every month, the team conducts a survey to calculate a net promotor score (NPS), which measures consumer loyalty, and grade the accumulated ratings as one number between -100 and 100. Penny’s score is 64 while the average NPS score for a health care organization is between 10 and 15. “The patients basically love Penny,” said Scalise. Black patients report even higher scores for Penny, a difference the team is eager to learn more about, as across health care Black women often report poorer experience of maternal care and undergo worse outcomes.
Based on what they observe, the team constantly improves the algorithm. For example, some patients asked questions about bruising or pain at their IV site. The team had not developed materials with the relevant information, so the system was not initially able to answer those queries. Once they identified this gap, the team added the appropriate content.
Scalise is pleased that their patients can use the virtual assistant to get quick and accurate answers instead of consulting “Dr. Google,” as she puts it, and finding potentially inaccurate or misleading information. The virtual assistant also supports continuity of care. “Penny connects them directly back to their team,” she notes. “So, it keeps patient care on a continuum.”