“Wrap around the family”: Doulas, community health workers push Texas to cover more services for pregnant women

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For Darline Turner’s clients, the hardest part of having a healthy pregnancy isn’t getting a doctor or designing a birth plan. It’s finding safe housing, getting enough food on the table or figuring out transportation to and from their appointments.

“We know to tell our clients, if you need housing, go over here. If your lights are going off, go over here,” said Turner, executive director of the Healing Hands Community Birthing Project in Austin. “We’ve organically built the networks to help.”

This important work got a big boost last session, when Texas began requiring all pregnant women be screened for non-medical needs, like housing, transportation or food insecurity. The legislation offers Medicaid reimbursement to doulas like Turner, as well as community health workers, for their work performing these screenings.

“The reimbursement isn't great,” she said. “But my other reimbursement was zero.”

As state legislators return to the Capitol, advocates are hoping the momentum around this issue from last session will continue, ensuring that there are increased social services to meet the demands that these screenings will reveal.

“We think of this as putting a foot in the door toward the right direction,” said Shao-Chee Sim, executive vice president for health policy at the Episcopal Health Foundation. “But we know it will also raise more questions about the entire ecosystem and the services and health care we are providing.”

Many advocates are also hoping that this represents the “foot in the door” for doulas and community health workers who want their services covered by Medicaid.

Medicaid currently doesn’t cover services provided by doulas, non-medical providers who guide women through pregnancy, childbirth and the postpartum period. Similarly, community health workers rely heavily on grants and private funding to maintain their work helping people navigate the health care system.

While both doulas and community health workers perform a wide range of services that go far beyond just screening patients for non-medical needs, getting Medicaid to cover even this narrow scope of work is a step in the right direction, Turner said.

“We always knew the state [would] catch up,” she said. “The important thing is that we're doing what we can to wrap around the families that we serve, because otherwise it's a wild and wooly world out there.”

Covering screenings of pregnant women

Last session’s House Bill 1575, carried by Rep. Lacey Hull, a Republican from Houston, and Sen. Lois Kolkhorst, a Republican from Brenham, didn’t make as many headlines as other women’s health priorities, like extending postpartum Medicaid or lifting the sales tax on menstrual supplies. But for those in the maternal health field, mandating screening of pregnant women for non-medical needs was a “monumental step” forward.

“When we think about how challenging and complex pregnancy is, this is a recognition of that,” Sim said. “Let’s try to tease out these different challenges and actually help you solve for them.”

There’s been a growing awareness in the maternal health field that a healthy pregnancy doesn’t begin and end with the care a patient receives from their doctor. All the prenatal vitamins in the world won’t matter if a pregnant woman can’t get to the doctor, or doesn’t have safe housing to return to after their appointment.

Community Health Choice, a Houston-area managed care organization, has been using community health workers and nurses to do this type of screening for several years. CEO Lisa Wright said figuring out a patient’s barriers on the front end reduces missed appointments, increases compliance with treatment plans, and lowers everyone’s frustration.

“We often think about getting a patient to and from the doctor, but can they get to the pharmacy?” she said. “Can they stop at the store because they may have to pick up baby items?”

Many groups in Texas had already been doing this work, largely uncompensated or with support from time-limited and perennially uncertain grant funding. By requiring these screenings and putting Medicaid funding behind it, HB 1575 represented a significant endorsement of this model, Wright said. The hardest work lies ahead, though, in ensuring that the social services system is prepared to address these needs once they’re identified.

“We're dealing with a population with a lot going on in their lives, and you want to be that one stable force,” she said. “When someone is experiencing an issue, they can't simply take a phone number for a resource. You’re going to have to, at least the first time, hold their hand through the process.”

After a pilot program, screening began in earnest in September, so the data is too limited to know exactly what the next steps will be, supporters of the legislation say. But while those trends emerge, they’re hopeful that lawmakers will increase funding for social service for pregnant and postpartum women.

“If you’re going to ask the question, you need to be able to respond to it,” said Jason Rosenfeld, the director for Community Health at UT Health Science Center San Antonio. “These are clients who are typically more vulnerable, and to ensure that both them and their children have the best leg up, we need to do more than just ask what they need. We need to have a response to get it to them.”

More access to doulas

HB 1575 also represented a significant step forward for doulas and community health workers, two professions that have largely been unable to bill Medicaid for their services.

Medicaid pays for half of all births in Texas, so covering doula services would significantly increase the number of pregnant women who can access this guidance and support, said Morgan Miles, the executive director of GALS, a community-based doula organization.

“We provide non-clinical care that addresses those social determinants of health and the holistic care of a person, and then also the fact that we improve health outcomes and reduce inequities in our maternity care system,” she said. “Doulas deserve to be paid for that.”

While many doulas only offer birth support, others like Turner provide a wide-range of support, helping clients with other health needs, signing them up for social services and public benefits, and providing home support after childbirth.

That’s why Turner was so enthused by HB 1575 and decided to get credentialed so she and the other doulas she works with could seek Medicaid reimbursement for the screenings. It’s been an onerous process — they had to attend training, get certified with the state Medicaid program, enroll in the provider system, and then sign up with each individual managed care organization, all for less than $150 per initial screening.

But she’s hopeful that it could lead to more of their doula services being covered by Medicaid. The Texas Doula Association, which Turner and Miles are both members of, is working on legislation that would allow Medicaid patients to access the full scope of doula services. Rep. Christian Manuel, a Democrat from Beaumont, has filed a bill that would pilot a doula reimbursement program as a first step.

Community health workers 

Although they were grouped together on this bill, and sometimes work together with pregnant women, doulas and community health workers are two separate professions. Community health workers, sometimes called promotoras, are non-medical providers that help patients navigate the health care system.

“We were the first state to create a statewide certification program for [community health workers],” said Sim. “But now, other states have caught up and surpassed us, and we're definitely not a pioneer in terms of finding ways to pay them.”

Many of them serve in roles that already do the screening laid out in HB 1575, serving as patient navigators, helping people enroll in health insurance, or in a home-visiting capacity to ensure people are following a treatment plan. It’s a model that’s proven hugely successful since long before Texas began certifying these providers in the 1990s, for pregnant women but also chronic care management and other specialty needs.

“If you are a community health worker dedicated to improving maternal health outcomes, then this is a great way of unlocking some of those dollars,” said Rosenfeld. “The question we don't know is, is the return going to be worth the time investment? And that's going to play out as we can continue to operationalize this legislation.”

So far, he said, community health workers who are affiliated with a larger system, like a hospital, federally qualified health clinic or health insurer, are more likely to go through the process to accept Medicaid reimbursement, compared to freelance or individual workers.

But much like with doulas, many community health workers are hoping this can be the first step to getting their work covered more fully by Medicaid.

“Where we are now, we’re here to collect data, demonstrate efficacy, and then take it back to both state legislatures as well as the federal government, and say, what’s next?” Rosenfeld said.

Disclosure: Community Health Choice and Episcopal Health Foundation have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.