care in GDM, overcoming bias and supporting high-risk populations during pregnancy. My name is Kartik Venkatesh, and I will be moderating today's webinar. To share a little about myself, I'm a maternal-fetal medicine specialist and perinatal epidemiologist here at The Ohio State University. I'm passionate about pregnancy care for individuals living with diabetes. I primarily conduct clinical trials and observational studies focused on patient-centered diabetes care in pregnancy. Here at The Ohio State University, I run our Diabetes and Pregnancy Program, and we see about 1,000 women from across the state of Ohio here every year, and I'm actually fortunate to be in our diabetes clinic today, as I am every Thursday, and really looking forward to spending the next hour with all of you. This activity has been funded by an unrestricted educational grant from Blue Cross Blue Shield Association of Minnesota, who has made this program a possibility. Thank you. Before we begin, I would like to quickly go over a few housekeeping items. Please keep in mind that this presentation is being recorded. Out of respect to our speakers and panelists, your cameras and microphones have been muted. However, it is our intention to ensure that we provide you the opportunity to ask your questions. Throughout the presentation, you will have access to the Q&A function found at the bottom of your screen. If you have any questions throughout or after the presentation, please feel free to utilize the Q&A function to ask your questions. You will also have the option to ask a question anonymously. We will do our best to answer all questions throughout today's presentation. Please note today's agenda. We will begin with a few introductions, proceed with our presentations, and wrap up with a Q&A session. We will utilize a chat box feature to provide you with supplemental links to materials. As a participant, you will also have access to the chat function. Please feel free to use this function throughout the presentation for comments. As previously mentioned, the Q&A function should be reserved for questions only. Now I'm excited to introduce you to today's panelists, all who bring expertise and unique perspectives in the maternal health space for diabetes care. First, I'd like to introduce Dr. Ebony Carter. Dr. Carter is an Associate Professor and Director of the Division of Maternal-Fetal Medicine and the Department of OBGYN at the University of North Carolina at Chapel Hill. She serves as an Associate Editor for Equity at Obstetrics and Gynecology, also known as the Green Journal. Her research focuses on group prenatal care as a tool to promote health equity and is funded by the Robert Wood Johnson Foundation, National Institutes of Health, and the American Diabetes Association. Second, it is my pleasure to welcome Dr. Lin Yee. Dr. Yee is a Tenured Associate Professor and the Thomas Watkins Memorial Professor of OBGYN at the Northwestern University Feinberg School of Medicine, where she leads a large research program that conducts clinical, public health, and health services research about pregnancy and the postpartum period. Dr. Yee's work focuses on social determinants on obstetrical health, health equity, patient-centered outcomes, the development of health promotion interventions for underserved pregnant people. She has a particular interest in diabetes during and after pregnancy, including the use of health services interventions to promote the long-term health of people affected by diabetes during pregnancy. Also, you will find the fact that both presenters do not have disclosures. We are excited to have this decorated duo present today on Empowered Care in GDM, Overcoming Bias and Supporting High-Risk Populations During Pregnancy. We hope that by the end of today's presentation, you will be able to, one, recognize evidence-based strategies for GDM management during pregnancy, tailored to the unique needs of high-risk communities, and two, recall the role of team-based care that addresses the specific social and economic barriers faced by women in high-risk populations during pregnancy. Let's get started. Thank you so much, Dr. Venkatesh. So it is wonderful to be with all of you. I was going to say good afternoon from the East Coast of the United States, but it was so cool to see all of the shout-outs. So I will also say good afternoon and good evening to our colleagues from around the world. I'm really happy to be here and to share a few minutes with you about a subject that I care very deeply about. All right, so Dr. Venkatesh already went out over our objectives, but just to reduce, we're on the same page. We're going to spend the next few moments recognizing evidence-based strategies for GDM management that are tailored to the unique needs of high-risk communities. And so I have taken the liberty here of putting some of these promising evidence-based strategies into a few bins for us. So we can look at this from the perspective of cultural centering strategies, so being very mindful of the native tongue that our patients are speaking, making sure that it's not just them, right? It's a family affair. I love diabetes clinic around Thanksgiving time because people are upset, like, what am I going to eat? So making sure that we are including the entire family, and then adapting intervention content to these specific cultural contexts. There are also some promising strategies, and I would love to hear from those of you all who are here because I'm sure we can all learn from each other, but technology enhancements, so mobile apps for GDM self-management, remote monitoring, and mHealth platforms. There are innovations in the way that we're delivering care, incorporating community health workers, interventions in clinics, and home-based support systems. And then we can also look at social and community support, such as doulas and community health workers, and looking at this from a policy and advocacy perspective. So I was given 15 minutes to walk you all through this, and I could give kind of a surface level of attention to all of these, or we could take a deep dive into one. So what do you think I decided to do? And we're going to talk about one of my favorite topics today, which is group prenatal care models and how these might be adapted to take care of patients who have gestational diabetes. So I'm not sure if everyone here is aware of group prenatal care. Centering pregnancy is the most commonly practiced form of it in the United States. Outside of the pregnancy context, these are often known as shared medical appointments, but I'm just going to walk you through it so that we're all on the same page. So let's say that you or your loved one is pregnant, and you go to your typical prenatal visit, and you usually sit in that waiting room for a while. Well, with group models, there's no waiting. You go right into the group space, you get your snacks, and then you essentially check your own vital signs. You check your own blood pressure, you check your own weight. So if I have a patient seen in triage who's been in one of the group care programs, I'm like, hey, what has your blood pressure been running? They know because they're empowered and they have been keeping track of their own numbers. The first 30 minutes is taken with something called mat time, and you see a picture of that here in the middle. So they meet with the OB clinician, you check heart tones, make sure baby's growing well, and then say, is there anything that's bothering you today? So let's say a patient says, you know, I have this pulling feeling in my groin that's really bothering me. And once I kind of know what's going on, I'll say, do you mind if we take that to the group and discuss that in the group? And usually they don't mind. And so when we get to the group and they share that complaint, the other person in the group who's on their fifth baby is like, girl, let me tell you about that round ligament pain. That got me my last pregnancy too. So the wisdom, the knowledge, and the power is coming from the group setting and not from me as the clinician. So groups of six to 12 pregnant patients of similar gestational ages sit in a group just like the one you see here in the third picture. And they receive all of their care in this group space. You have two hours. So it's not like the 10 minute wham, bam, thank you, ma'am, where it's all medicalized and you're just trying to make sure you check all the boxes of pregnancy. You have time to talk about things like infant care. I remember the first time I attended a group, my oldest daughter was four months old and they were talking about feeding. And the fact that when a baby is crying, that's actually a late sign of hunger. And I had figured it out by then, but oh, how much more amazing would it have been to have been in a group and have time to talk about all of these other topics. So groups were traditionally designed by midwives for low risk pregnant patients. But by the time I'm learning about this, I am a high risk obstetrician fellow. And I wanted to see, could group care be applied to some of the tenants of my high risk patients? And greatest among that group were patients who had diabetes. And so this is a picture, it is used with permission, and this is the first group of patients that I cared for when I was a fellow in diabetes groups. And I thought, you know, there's all of these promising outcomes in low risk patients. Can we apply it to our patients who have diabetes during pregnancy and see if we can actually improve outcomes? And then one of the other things I wanted to share with you in terms of pictures, this is that same group five years later, coming back for a birthday party with all of the kids who are at this point five years old. And this is us hilariously trying to do yoga and other activities just to start trying to move and change things. And so I didn't know what I was doing when we formed this group, and I admitted as much to them. And I said, we're going to go on this journey together. Tell me what you like. Tell me what you don't like. We used the evidence that was available and essentially co-created a curriculum together to do diabetes group prenatal care. So at the point that we did this, just kind of as proof of concept, the question is, what is the evidence? And at the time, there really wasn't much. And so the journey I'm going to take you all through in the next few minutes is let's look at the literature for group prenatal care or shared medical appointments during pregnancy for people who do not have diabetes. Let's look at the literature for shared medical appointments for patients who have diabetes but are not pregnant. And then let's see the intersection between this Venn diagram and when they come together. So first of all, starting with pregnancy. This was the study that initially got me interested in group prenatal care in the first place. It's a cool form of care. You probably heard my excitement about it, but it was this study that essentially randomized about 1,000 patients at Emory and Yale to either receive group care or individual care. So these are low-risk pregnant patients. They do not have diabetes. And what they found was interesting. Among patients randomized to group, they had a 33% risk reduction in the risk of preterm birth. The folks in the audience who don't do pregnancy and it's like, why are you always talking about preterm birth? We love preterm birth as an outcome because what is the number one predictor of whether a baby lives to see their first birthday? It's if they were born too soon. And that doesn't just have implications for the baby. It also has implications for the mother because if you have a preterm birth, your risk of having future cardiovascular disease or a cardiovascular event just went up by two to threefold. So it's a powerful marker in many ways. And in this study, just a group care intervention, no medicine, nothing else, actually improves outcomes significantly. And then they did the subgroup analysis of Black patients in the sample. There was a 41% risk reduction in preterm birth. The disparity went away. And that's actually why I first got interested in this form of care because it was the first intervention that seemed to have the promise of making things better. So I went on as a fellow and I wanted to see all of the literature that had come into group care up to this point. And I did a meta-analysis. Meta-analyses are my favorite study designs, my favorite study type, because even when you're broke, you can still do them. You just need to have the skill set to do them. And so I did a meta-analysis looking at all of the group care literature up to this point. And what I found was rather disappointing. There was no difference in preterm birth. But when we did the subgroup analysis and high-quality studies that included Black women and actually kind of separated them out, guess what? There was still a significant risk reduction, 45% among Black patients who had received their care through group. And this was, you know, whether you're talking about observational or randomized studies. So my working hypothesis of group care is it's fun. It's wonderful. You're going to enjoy it. But the segments of our population that probably have the best shot of having improved outcomes are those among us who have the highest risk of having adverse outcomes, including the patients we care for who have diabetes during pregnancy, whether that's preexisting or GDM. And so, you know, I want to be honest about group care. Even though I love doing it, it's harder than individual care. Having a group of 6-12 people who can all come at the same time every 2-4 weeks, implementation can be hard. There can be low uptake when we go and we offer, you know, we have this wonderful program for patients who have diabetes in pregnancy, you know, do you want to come? There's pretty low uptake. Only about 55% of patients tend to say yes. We've realized that if we kind of offer it as the default for everyone who has GDM or well-controlled type 2 diabetes and people just come, they love it. Only 55% of them will stay, but getting people to come in the door the first time can be very difficult. And then I think in some of the studies there can be confounding. So a lot of the studies of group care that were early looked promising, phenomenal outcomes. And you see some of the later ones, and that effect size seems to be attenuated somewhat. And I think it's because in these later studies, whether you randomize them to group or individual care, it's the same clinicians providing it to both. And I think once you do group care, it changes the way that you show up for patients. And so you're probably bringing some of those tenants you've learned from group care over into your individual care space, which is great for the patient, not as great for our research studies. So at this point, I actually want to move over to looking at group care. I'm going to call it shared medical appointments outside of pregnancy for patients who have diabetes. So these studies have patients with type 2 diabetes. They are not pregnant. So I'm over to my other side of my Venn diagram now. And what you see is that there is a significant reduction in the hemoglobin A1c by almost a half of a percentage point for patients who received their care with shared medical appointments in this meta-analysis, including thousands of patients. And if you take a deeper dive into this meta-analysis, they showed that shared medical appointments are more effective than traditional care with regard to lowering patients' A1c. Patients tend to be more satisfied with their care. They get better self-management skills. And it seems that the longer you participate in these shared medical appointment interventions, the more the effect increases in terms of your duration of participation. Why is this? And the authors of this meta-analysis give us a few suggestions of what might be happening. So the peer support, I will tell you, I've anecdotally seen this myself as a clinician. So if I have a patient with GDM who's in one of my diabetes groups, and it's at the point where we really need to start insulin, and the patient's like, nope, not doing it. I hate insulin. I refuse. I'm not doing this. The patient who's had type 2 diabetes in the group already for five years is like, you know, it's really not that big of a deal. I just do this, and the pin actually hurts less than my finger sticks. And they go on, and they have a conversation, and she takes the insulin because she trusts her friend. She trusts the lived experience and expertise in a way that is so much greater than anything I can ever say as her clinician. You also get extended time. So we're talking, you know, a couple of hours and not these quick visits. There's the interprofessional team support. So when we do groups, it's me as a clinician, and then I also have a diabetes educator with me kind of caring for these patients together. And then there's also the focus on patient education and self-management and support. I want to share with you one additional systematic review and meta-analysis. This is 47 studies. We're talking about 9,000 patients, and they had very similar findings so that these group visits were generally associated with lower A1Cs, fasting blood glucose, body weight, waist circumference, and diabetes knowledge. So I'm going to take this part of the talk home and say that diabetes group care may be effective in improving glycemic outcomes, diabetes knowledge, and some diabetes-related behavior. But I also want to be fair and honest and say there was significant heterogeneity among these studies in terms of the way they were designed and the way that the interventions were administered between the different studies. And so now let's put it together. And if I take myself back to, you know, I was a fellow. We created our diabetes group prenatal care program at Washington University in St. Louis where I was at the time. And then there was nothing at the center of this Venn diagram. There was no, I thought it might improve things. There was no data to show us what to do. And so I decided we're going to do our own small pilot randomized trial to see, you know, are we right when it comes to this? And in the years that it took me to design and execute this randomized trial, literature came out. So lo and behold, several observational studies were published. Most of these three studies were in predominantly Spanish-speaking patients. And all of them had a signal for improved outcomes for patients who were getting their care in diabetes group care. So we're now at the intersection, diabetes and pregnancy and what's happening in the literature. And so this is our publication of our pilot randomized trial that we did at Barnes-Jewish Hospital in St. Louis, Missouri. And I want to just briefly share with you some of the things that we found. So our primary outcome was diabetes self-care activities. And I will tell you, as long as I live, I will never have a subjective finding like this again as my primary outcome, because what we saw is the patients were like, we're great, we're wonderful. We always do exactly what we're supposed to do. And so you didn't really see much of a difference because I think everybody overestimated how great they were controlling everything. But this is a model of the curriculum that we use. So the very beginning when everybody's doing their individual assessment is at the clinician's discretion. And then the closing and how you bring it together is at the clinician's discretion. Just as a practical matter, we usually group care begins in the first trimester with the patients all being together. They go through their entire pregnancy together and they all deliver together. Well, we realized a few things in St. Louis early on where this was not gonna be possible. One, I had wanted to focus these groups on GDM. Most of the patients already had type 2 diabetes. There were not enough patients to keep group sizes large enough. So we actually combined GDM and type 2, and it ended up being a beautiful thing because patients with type 2 could tell the cautionary tale to patients with GDM and provide them with support as they were figuring out what to do. So it actually was a beautiful exchange completely by accident. So each group covers a pregnancy topic. So for example, pregnancy discomfort and how do you handle that? And then a diabetes topic such as meal planning. And we always had snacks and there was a Panera right across the street from our office. And so one of the activities would be ordering the snack for the next week. And so people would go on and Panera has a really nice website and order all of this stuff. And there'd be like a billion carbs in our snack by the end. And we'd say, wait, how can we redo this and go back and change what we're ordering? And so trying to make it very practical in terms of people's lives. And then a behavioral health topic. We saw that a lot of our patients had depression, anxiety, and you can't handle your diabetes well when your mind is not feeling well. And so talking about self-care and there was always a behavioral health topic. And so these are some of our findings. So we looked at gestational weight gain and because this was supposed to be a GDM trial, patients didn't qualify for the study until they were well into the second trimester. So gestational weight gain overall throughout pregnancy did not change. But if you just looked at the weeks that they were in diabetes group care compared to individual care, there was a significant reduction in their weekly weight gain for patients who were randomized to group. We had half patients with type two, half patients with GDM. There was no difference in A1C, although the A1Cs in the group are looking more promising. And then we also looked at the patients with GDM. There were no differences in A1 versus A2, so diet versus medication control. But here's the kicker, and this is what I really love about this study. In our patient population, patients with GDM coming back to get their six-week postpartum GTT, our rates were terrible, like 20%. We tried to do all kinds of things to get these numbers up because when you think about long-term risk reduction strategies, we need to know where people are then so that we can kind of help them set off on the right course. And what we saw is that patients who were in diabetes group with GDM were almost four times as likely to come back and get their six-week GTT, which is huge. I haven't really seen other interventions with that kind of an effect size. And so we then took it forward. So my pilot randomized, or my, sorry, let me back up. We did the pilot, and then we got funding to do a definitive trial of diabetes group care. So excited. And what happens? A pandemic. And what do you do when a pandemic shuts down your diabetes group care program? Back to my favorite study design, a meta-analysis. And so we did a meta-analysis of all of the studies of diabetes group care that have been done up to this point. And we looked at outcomes such as LGA, and there was really no significant difference in LGA, or preterm birth rates for diabetes group care versus individual care. Some of the more promising things that we found, so LARC, long-acting reversible contraceptive uptake, and especially if you have type 2 diabetes, pregnancy intention is important in making sure, if you're seeing me as an MFM, when you're like well into the first trimester, you can argue in many ways that's too late. We need to see people beforehand. So pregnancy intention and LARC uptake was significantly improved. And then the same signal that I saw, told you that we saw in our own data, patients in groups are significantly more likely to come back for their postpartum GTT testing than patients who are not. And so why may group care be working? And I really love this review. It's a qualitative review that kind of goes through shared medical appointments outside of pregnancy, and what's happening with them. And so as you look at these mechanisms, combating isolation, vicarious learning, feeling inspired by successful peers, firsthand health knowledge, increasing trust in your clinician, these are all acting on the patient. I want you to pay attention to the other colors here. Friendships between patients and clinicians, improved collegiality, clinician learning, adequate time allotment. I'll give you a easy example of a patient who used to always be on my individual care schedule. She was always late. She was always my last patient of the day. So I'd be late getting my kids in the process. And she ends up in one of my diabetes groups. And in group, she's activated, she's engaged. I start to learn some things about her. Like she takes three buses and walks 20 minutes to get to my clinic. That her partner is unkind to her. That she has housing insecurity. She has food insecurity. And you better believe when I know all of these things at play in her life, when I see the social drivers of health at play in her life, I show up differently to care for her. And so I would argue for patients who are coming from historically marginalized identities, who might be very different from their clinicians in terms of their race, gender, economic status, the neighborhood they're living in, it takes time to build relationship. And so I think the mechanism by which these interventions really are working is inadvertent. They're inadvertently working on us, the clinicians and the healthcare systems in which we function. And I wanna take that step just a point further. And in all honesty, I adapted this figure from Dr. Joy Creperi. Because when I heard her deliver it, it made perfect sense to me. We often started the social determinants of health or the social drivers of health as if that's the end all be all. Like lots of us are doing screening for this in our clinics. And if we start there, I will argue that we will miss the mark every time. We actually have to go deeper. What are the root causes? So the social determinants of health are as they are, because there are power and wealth imbalances. And why is that the case? Because of institutional racism, class oppression, gender discrimination and exploitation. And until we get down to these root causes, I would submit to you that we will continue to miss the mark and appropriately caring for our patients with historically marginalized identities. And so in summary, I will say to you that I think that the verdict is still out. And I'm not proclaiming at all that diabetes group care is the end all be all for everyone. But I would suggest to you based on the data I showed today that is certainly a promising strategy and one that warrants further study and effort. And a special thanks to my research team who is still finishing up our definitive trial of diabetes group care in St. Louis. And I look forward to having the definitive answers ready to share with you soon. Thank you so much. And I will happily turn it over to Dr. Yi now. Thank you all. Just making sure you all can hear me. I'm really excited to be here talking about this important topic. I always enjoy hearing from Dr. Carter as well. I think we have so many synergistic interests and it's great to hear about the work you've been doing. And I'm really excited to hear how many of you are from places not just around the US but around the world. I hope that what I have to share with you today is not too US focused, but obviously many of the things we're going to be talking about are applicable in many different contexts. So let's talk today about our main objective which is to recall the role of allied health professionals in providing accessible team-based care that addresses the specific social and economic barriers faced by pregnant people in high risk populations. I'm gonna walk you through a few key sub-objectives of this. I wanna first talk about why we should understand patients' lived experiences and how getting to know their lived experiences like Dr. Carter just spoke about can really enhance the quality of your care. Two, I'm gonna talk a little bit about the concept of team-based care and how to develop or why it's important to develop diverse teams that may include people like community health workers and navigators and peer support, but also effective use of technology dovetailing a bit more off of what Dr. Carter spoke on. And then I wanna end by talking about health literacy as a universal precaution. And in particular, the idea that we should employ a low health literacy for all approach to our care. So first let's talk about understanding participants and patients' lived experiences. I wanna posit that there are a couple really key reasons why this is critical. I think we all understand, as Dr. Carter showed, that there are many, many contributing factors to why patients may have challenging times caring for their gestational diabetes or their obstetric health in general. And that the roots of disparities and inequities are not about race, which is not a biological construct, but it's really about the many deep and complex underpinnings of why there are disparity or why there are differences in health. These include things like stress, knowledge and education, language, exposure to physical and built environments with differences, self-efficacy, empowerment, bias, structural policies, and so on. And really taking those to heart, I think we can think about how on a policy and public health level, these concepts are incredibly critical to understand so we can make big change. But on a local level too, it's equally critical to understand how these individual level exposures can affect our care. So how can understanding patients' lived experiences enhance quality and equity? I pose to you here three reasons. One is that social, educational and economic barriers heavily influence gestational diabetes self-management and outcomes. You know, one of the reasons I particularly love caring for patients with diabetes during pregnancy is actually that it is a condition that is so intertwined with one's social determinants of health and their lived experience. This is different from patients with, for example, maybe a fetal anomaly or maybe lupus or various other conditions. In diabetes, you have everyday lived experiences, whether it's through your food, your social interactions, your neighborhood environment that affect how you're going to do with your diabetes outcomes. And that's one of the reasons why I think it's not only an interesting condition to care for patients and understand them deeply, but also to develop interventions that can improve their wellbeing. Two, understanding individual social needs and their lived experiences allows clinicians to tailor their support. Care is not one size fits all. And by understanding where patients are coming from, we can provide care that is customized to individual needs. And then three, learning about lived experiences builds trust and offers opportunities to capitalize on drivers of success. We often talk a lot about negative social determinants of health or adverse social determinants. And while those are very impactful, I also think that learning about facilitators of positive health are really important and maybe even more important in understanding how to support our patients. So let's talk about a few examples. I wanted to share with you some work that I did. Actually, it's been a long time now, a number of years ago, but really set the stage for some of the intervention work that I do now. And this was about deeply understanding patients' lived experiences, both barriers and facilitators, to caring for themselves during a pregnancy with diabetes. This study included people with both GDM and type 2 diabetes, but I think conceptually the barriers I'll share with you are very similar regardless of whether it's gestational or pre-gestational diabetes. So first, one of the major barriers to successful self-care included social instability. This included the experience of social chaos, lack of social supports, violence, either interpersonal violence or in-neighborhood violence that might've precluded exercise, having financial instability and an inconsistent schedule, and then a chaotic lifestyle. We all as care providers understand how diabetes really requires a lifestyle that includes scheduled activities for monitoring and eating, and that can be very challenging for many of our patients. Just to share with you a few quotations here and on the next few slides, one of my patients, one of my participants said, the only thing that's helping me is getting a, Illinois we call it a link card, food stamp program card, but sometimes that doesn't even help since I'm living with family and I don't really have money for myself because I'm helping get food for everybody else. I have nothing for myself. So poor social support, limited access to food. The second participant commented on violence and this went along with her contextual explanation of why she couldn't exercise after meals. Second barrier that I talk a lot about with my patients is this concept of disease novelty. And the idea that every time you're encountering new knowledge, there's a high cognitive burden to having gestational diabetes, especially when people are expecting a normal uncomplicated pregnancy. And then we are introducing a high health learning state with lots of action that's required. So a patient said, I'm actually shocked. Every week I'm shocked. Each week it's something new. Another patient said, at first I didn't know what it entailed or how much it was gonna be a big impact on the whole pregnancy. I'm like, oh my God, I didn't know all the effects I had. I didn't know all the things you had to do and keep up with. It was a lot. And I had no idea because I never had it. I think that is probably a comment many of you have heard from your practice or from your patients and that we see patients feeling very overwhelmed by the concept of this new diagnosis. And this indeed is not only an educational social determinant of health, that's a barrier to care, but also about exposure and social support and how somebody incorporates new knowledge in their pregnancy care. The next barrier to care that I've explored is this concept of stigma and psychological burden. Many people who have a condition during pregnancy and GDM is, I would include in that, feel isolated. They feel their pregnancy is more stressful than it might've been without that condition. They feel overwhelmed and they feel that it can have this concept of stigma and blame. Why did I bring this upon myself? What could I have done to not have had gestational diabetes? There's also this concept of fatalism that nothing I can do will make a difference, so why bother? And then for patients who have preexisting mental health conditions, we know that having gestational diabetes on top of that can amplify the risk for anxiety and depression. So a patient told me, you just snack on stuff because you feel like everything's going down the drain instead of eating the salad or walking around or being happy. The more sadder you are, the more your health goes down. Or the bottom quotation, diabetes eats you up on the inside. No matter how good you are in taking care of yourself, no matter how well you exercise, something always goes wrong. That's some of that fatalism. One of the next burdens we talked about was this concept of failure of outcome expectations. Any of you who are diabetes educators have probably seen this. And this is this concept of failing to believe that treatment will change outcomes and failing to participate in goal setting as a result of that. And this I think is a really complex social determinative health because it's this concept of both denial of the severity of condition, but also not having the self-efficacy or empowerment or feeling supported that they can make meaningful change. Participants said, I eat you up on the inside. And this is sort of like what I just, actually a similar quote to what I just showed you before. And it really shows you that participations often experience this deep sadness about their condition and don't believe they can fix it. The next quotation or the next theme I looked at was about the burdens of GDM management. And I'm sure we could talk about this for an entire hour. We know that participants have more frequent appointments. They have to deal with the logistics of childcare, transportation, work. They have to deal with the task burden of glucose monitoring, logging in medications, and they have to prioritize their GDM in comparison to other more immediate needs. So sometimes GDM falls low on that list of priorities if things like housing instability or violence need to take priority. You have a patient here who says, you get tired. You got a lot of stuff going on at home. You get stressed about taking that medicine, sticking yourself. I got to stick myself, check my sugar, dah, dah, dah. It becomes frustrating and people get burned out. And then nutrition barriers. Again, worthy of an entire hour, but we know that not only is this concept of nutrition novelty, not maybe understanding or been exposed to some of the new foods that were recommended, but people often have low self-efficacy or they don't believe that they can make the change. This is not just because of bullet point three about cost and access to healthy food, but also about having the sort of internal feeling that you are able to make change. There are also people who lack power to make family food decisions and have challenges with cooking for food for the family or give up their food for other members of the family. And then you add to that cultural preferences, personal preferences and meal scheduling difficulties, and you can have the perfect storm of nutrition barriers. Person said here, this is one of my actual patients. I remember when she told me this. Well, all these are my patients, but I definitely remember this one. Cravings, I'm a sweet person. I love cakes and cookies. I'm going to eat the whole cake. And I'm not talking about a little piece, oh, how cute. No, I'm talking about, I will eat the whole damn cake. She literally ate an entire caramel cake and then came and told me about it. But as I mentioned before, it's not all adverse social determinants of health. I also want to bring up that understanding patients' lived experiences includes understanding the facilitators of their care. People are motivated to do well. And oftentimes it's not just because of their own health, it's because of this external motivation for their family, their fetus. Patients told me, you got to take your medicine and not have to risk to have a healthy baby. It's like there's no winning or losing situation. You've got to do, you have to do what you got to do. And again and again, patients would tell us when trying to understand facilitators of self-care, they were motivated by their fetus or their existing older children. There's also this concept of self-regulation. Patients wanting to know their data. They want to know if their log is showing improvement, if their A1C is showing improvement. And having that feedback of their own data helps them then make change for the future. That's called self-regulatory behavior. And then finally, developing more knowledge. So educating our patients makes a difference. It helps them feel like they're in control of their condition. So take action. How can we take action in understanding lived experiences? Actively listen and be genuinely curious about patients' lives. We need to make time for this. It helps us understand how to tailor their care. We need to understand how their lived experiences interact with their GDM care so we can provide tailored support and education. And we need to incorporate social needs assessments in routine care. We also need to apply motivational interviewing to piggyback on patients' motivating factors. Don't just focus on the negative. Use those motivating factors to help them move forward in a positive way. So just moving ahead, let's talk about team-based care for a little bit. So I think that we all understand that GDM care takes a village. And I want to pose to you that all the people on this slide really should be a part of that village. There's the core clinical team, the physician, midwife, nurse, nutritionist, diabetes educator. I think these are the essential elements of your GDM care team. But we would be remiss if we didn't include the wraparound support. In some places, this might be a patient navigator. I do a lot of work on that. In some places, it might be a mentor or peer support, like in a group care setting. They might, as I said in bullet point three, group care team members. It also includes your medical assistant team members who might not be having in-depth interactions with the patient, but are still equally key. And then don't forget your psychosocial team members, your social workers, psychologists, other mental health specialists, or maybe community support groups. And then we often forget about the importance of our administrative staff. That's the person your patient sees first when she walks in the door. That administrative front desk staff, the telemedicine or tools that are involved in the patient's care are key to helping her feel engaged and welcomed in the team-based setting. I wanna bring up a few research concepts that are in progress about patient navigators and peer support. There's a lot of really interesting work going on right now and some of it's from my team about the concept of patient navigation. This is a patient-centered intervention that uses trained personnel to facilitate complete and timely access to health services. And the core concept of patient navigation is that it's about focusing on social needs and healthcare coordination to improve self-efficacy, advocacy, care engagement, and short and long-term retention in healthcare. And navigators often are trained lay people. They do not have to be nurses. They may be with lived experiences, but they don't always have to be. And there's a lot of data that's emerging. Some of it from my work in the Navigating New Motherhood and Suite Studies that shows that patient navigation is successful in the postpartum period. In our suite study, we found actually that nearly 100% of participants who had a navigator saw not only had their GTT completed at the six to 12 week time period, but saw a primary care doctor within a year after having had gestational pregnancy with GDM. So that was really exciting. And then Navigating New Motherhood is looking at similar concepts in a larger postpartum population. I think that there's emerging data also about peer support. So we talked a little already in Dr. Carter's work about group care. There's also some work that's about buddy programs and pairing mentor mothers with other people who are new to their pregnancy with GDM. The concept of mentor mothers is well-established in other areas like HIV care and global health. And I think it's something that we need to explore more in GDM and other aspects of diabetes care. I think though that when we talk about the care team and building a diverse care team, we have to also remember the role of technology. And I just want to highlight three elements of technology here. One is EMR portals. So EMR portals outside of the pregnancy context are associated with better patient satisfaction, actually inside of pregnancy context too, more frequent patient-provider communication and improved adherence to care. This is not very well-established in the diabetes context in pregnancy, but outside of pregnancy, portal use is associated with a better A1C. Yet we know that there are many socioeconomic disparities in portal enrollment access and use. And so this is an area that is ripe for investigation, but I would pose to you as a provider that it's important for us to introduce portals to our participants and really ask them if they need help understanding it so that it's not just a resource that is glossed over. Second would be telemedicine for GDM care. This is increasingly common. We have many ways in which patients with GDM interact with their team members by either telemedicine appointments or sharing their glucose logs by electronic means, but actually the data on whether this improves glycemic control is fairly mixed. Nonetheless, I would say that it's an area that's expanding and we need to develop that data. There are limitations, of course, of Wi-Fi access and technology literacy, and we have to be very conscientious about disparities in coverage of Bluetooth-enabled glucometers. And we have to make sure that telemedicine disparities don't exacerbate existing disparities in GDM. With acknowledgement of those potential limitations in mind, I think this is important for everyone to understand patients' access to telemedicine and use it when it's appropriate for that patient. And then finally, mobile health technology. So texting, smartphone applications, sort of the way of the future, yet lots of evidence has also shown us that maybe it's feasible, maybe it's acceptable and improves health knowledge. We don't yet know if it actually improves birth outcomes. And then let's finally talk about how to take action on team-based care before we move on to the last section. So train a diverse healthcare team. Representation matters, and having a whole team that includes people outside of the traditional care model matters. This might include wellness coaches, this might include other types of nutritionists, this might include tech experts, peer support, patient navigators. And then use technology wisely. Meet patients where they are. Don't assume your patients want or desire technology, but check in with them about what they really need and focus on the quality of patient-clinician communication, perhaps more than quantity too. So then finally, let's talk about health literacy as a universal precaution. This is a really important principle for all of medical care, but I think especially for GDM where that cognitive load is so high, there's so much to learn in a short amount of time. What is health literacy? It is the degree to which individuals can obtain, process and understand the basic health information and services they need to make appropriate health decisions. And I would actually add in here that we need to consider health numeracy when we're thinking about patients with diabetes as well. We all know how much counting and math has to happen in order to read a nutrition label, dose your insulin, look at clocks and write schedules. And that math element, the numeracy element is a part of health literacy. Health literacy is considered a key social determinants of health. It is an important predictor of health outcomes. And in the non-pregnancy world, we understand that having inadequate health literacy is not just a predictor of things like ER visits and control of blood pressure and A1C. It is actually a predictor of death, of premature mortality. So it's incredibly important. We also know that it is distinct from language barriers or education. People can speak other languages and have excellent health literacy, but they also can have challenges with health literacy in their own language. It is also not directly correlated with education. While people with high education may have better health literacy, even those with graduate degrees may find the words and jargon we use in medicine to be overwhelming, and they may not always tell you that. So what is the relationship of health literacy to diabetes outcomes? Just to summarize sort of like 20 years of literature here, I will tell you a few of the findings. We know that in some populations, inadequate health literacy is associated with a higher hemoglobin A1C. There is a greater risk of hypoglycemia. There is a greater risk of diabetes complications like end organ damage. And we know that there's lower diabetes-specific disease knowledge and medication adherence and self-efficacy. We also know that completion of daily self-management skills like logging is really challenging for patients with inadequate health literacy, and that there is a decreased perceived quality of patient-provider communication when patients have inadequate health literacy. What about in pregnancy? So, you know, pregnancy plus GDM, or actually I should say pregnancy plus any type of diabetes, is a high health literacy demand. Imagine pregnancy alone is a high health literacy demand. A person goes from being a normal non-pregnant person out in the world and suddenly is growing a new human with a new set of healthcare demands and requirements that include learning about pregnancy, parenting, breastfeeding, postnatal care, pediatric care, and many other aspects of their life are changing. And you add on top of that, the roles or the education that's needed to care for yourself when you have diabetes, and this is an incredibly high health literacy demand. Some work that my team worked on from the New Moms to Be study found that inadequate health literacy among first-time moms was associated with suboptimal maternal and neonatal outcomes. This was not in a diabetes-specific population. It was an all-comer population, but we know that differences in health literacy contribute to perinatal health disparities, and that GDM then amplifies that cognitive burden, that already challenging experience. We also know that having an intersectional language barrier or educational limitation amplify health literacy and numeracy barriers. And then I want to just tell you a few examples. These quotations will not come as any surprise to anyone. Patients have said things like this in our study, because I didn't really understand. Okay, this has 15 grams of sugar. Well, if this has 15, this is 32, I'll take the 15. I didn't really know it had to do with the carbs. It could have 32 grams of sugar, it can have 13 grams of carbs, and I'm like, okay, that's not bad. Or once in a while, this is the only thing I read. Sugar is 23 grams, sugar is 64 grams. Once I see it's more than 23, I'm like, oh no, I can't eat it. Or a patient who said, reading labels is difficult for me because I'm not good at math. Then I'd just be like, oh my God, this is so complicated, I just ignore it. I'm confident we've all heard that, or have some patients who you think that's happening, but they may not feel comfortable telling you. I think it's also important to understand that health literacy can be a very shaming situation. And that's why the recommendations are to treat it as a universal precaution. Anyone can experience low health literacy. This is not a condition where, generally speaking, we should be screening for it. Instead, the recommendations from health literacy experts are to focus on clear communication with everyone, do not attempt to identify those who are thought to most benefit from specific efforts to improve communication, because by and large, we are wrong, and we miss people who need that added communication effort. But we also know that when you treat it as a universal precaution, it raises the level of knowledge for everyone. Even people who have higher health literacy do better if you care for them in a way that treats health literacy as a universal precaution. How do we do that? Well, taking the low health literacy for all approach requires all team members to be trained to use plain language. It requires asking open-ended questions and checking for understanding. It also requires active words, and this is sometimes really hard. Not only does it require reducing jargon, but using simple active verbs with fewer messages chunked together is really critical to ensuring understanding. That may mean not doing all of your GDM teaching in one one-hour session. It may mean chunking it up into smaller frequent sessions. We also need to repeat information in multiple modalities and have ways of using simple, tailored visual aids, and then don't forget that always, always using professional translators goes along with improving health literacy because it makes sure that we're doing it in our language. Don't attempt to muddle through an interaction with someone who's maybe would prefer a different language, and make sure you're using professional translators, not family members, because they, in theory, should be trained to use a low health literacy for all approach. So I will end by just saying that improving outcomes for people with GDM requires teams to provide whole person respectful care that appreciates individuals' lived experiences. We know that social, educational, and economic barriers heavily influence GDM care and outcomes, and as I said in the beginning, this is one of the reasons why I really like caring for patients with diabetes because their health outcomes are so heavily dependent on their social needs, and we can make a difference there. We also know that diverse, multidisciplinary healthcare teams must work together to understand and support individuals' barriers to GDM care, and I should have put on here they're facilitators too. Use your team members, use your doulas, your community health workers, your other team members who understand the patient's lived experiences outside of the clinic in order to get to the root of their drivers of success. And then finally, providing tailored patient-centered care with a low health literacy for all approach is essential for all team members, not just the physicians and nurses, but really the entire clinic needs to function in a way that understands that health literacy can be a barrier for anyone, and we do not always see it. It is an invisible social determinants of health that we should be looking out for and thinking about at the forefront of our minds all the time. We are, Dr. Carter and I are happy to take questions. I want to just click through here and show you some of our references for those who are interested. Dr. Carter's are here and mine are here, and we're both happy to answer any questions about what we've spoken about today. Thank you all. Thank you so much, Drs. Carter and Yi for that very informative presentation. And what a wonderful presentation that really was. We've had over 800 people log in for this lunchtime talk on the East Coast. At this time, I would like to encourage all of you who've attended to ask your questions and post them in the Q&A function at the bottom of your screen. We're gonna do our best to answer the questions in the next approximately 15 to 20 minutes. So I'm gonna start with some of the questions that were already posted while you were both giving your presentations. And first is a question for Dr. Carter, and a few people brought this up. And perhaps this was as feedback to when you talked about pivoting your own work during COVID when a lot of care delivery became virtual. Given the growing platform of using virtual-based approaches for prenatal care, what are your thoughts about virtual-based group care? How can that be done? Would you recommend that? It's also with regard to the intersection of social determinants. I know Dr. Yi also touched upon this as well. Yes, so we certainly tried to pivot to a virtual platform during the pandemic. And what we found is that our groups that had started in person, that had made it to at least the third or fourth group. So, you know, there tend to be a total of nine to 10 groups. The first two were awkward because people don't know each other. They're trying to feel each other out a little bit. And somewhere between group three and four, the secret sauce happens and people let their guard down and they feel comfortable. And it kind of just, you don't even have to do much from then. Like the patients just kind of take it forward and people are happy and they're friends. As long as we move to a virtual platform after that little secret sauce moment, somewhere between group three and four, the groups were fine. They were happy to see each other and it tended to work really well. When we tried to start de novo groups virtually, it never worked. And part of it was our hospital's platform because, you know, the mat time, the beginning part where you kind of separate out and see the clinician, we could not do breakout rooms. It defeats the purpose if you have to do the whole group and then pick up the phone and call everybody afterwards to do their individual assessments. Part of it was our platform. And then part of it is people don't want to sit on Zoom with some strangers, even if we did an abbreviated, you know, de minute group. So I know that there have certainly been positive examples. I know that there's actually like a company that has started that is doing virtual groups. So I know that it has been done. I personally have not had the experience of it going well. And the other thing that I think is really important is that relationship, the increased empathy, knowing the team that's going to be there who's going to advocate for you when you're on labor and delivery. So all of those things get a little bit harder when you don't have that warm touch point. But it's not to say it's impossible because people have certainly done it well. I would just add to that. I think it's really important for any virtual context, but especially a group care, to remember that many of our most underserved patients have a lot of anxiety over sharing what their homes might look like. And I find certainly this is true in telemedicine, but maybe even more of an issue with group care and the constant, you know, and the video issues around homes and potentially stigma can be really challenging. And sometimes anyone who's a caregiver or anyone who's exploring this concept of either actually group care or support groups may want to think about what kind of ground rules and boundaries they set around that in the future in order to be as de-stigmatizing as possible. We've had, for example, some GDM support groups that our social workers have run, and they sort of talk about that overtly in the beginning to make sure that people feel comfortable with each other despite some of those potentially stigmatizing issues. Thank you. Next question is for Dr. Yee, and this comes from our audience. That is a lot of interest in team-based care. And given the diversity of our participants, including many people who come from a nursing background as well as a doula background. So perhaps I think the question is, is it explicit or implicit that the team is led by a physician? And next, how could that model then be adapted to prenatal care models perhaps that are nursing-led or perhaps to a doula-based model that may be an adjunct to routine prenatal diabetes care? Thanks for that question. I do not think a team has to be led by a physician, but a physician has to be involved, or a nurse midwife or a nurse practitioner with obstetric experience has to be involved in the obstetric elements of care. But I don't think that that means that the physician has to be, so to speak, in charge. And some of our best care models are actually when the primary point person for the patient is, for example, a nurse or nurse practitioner who serves as the main point of contact, perhaps their main diabetes manager of care or co-manager along with the patients, and then serves as a connection to all the other team members. Maybe they see that nurse or nurse practitioner every week, perhaps sometimes in person and sometimes telemedicine-wise, and they see that physician maybe only once a month. I think that there are many ways of doing this in which the physician does not need to be at the center or should not be at the center. And actually, care models are much more sustainable if we can make that happen, if we can make sure that we don't just rely on physician availability for keeping the team together. I will add, I guess every state has slightly different billing rules around what can be done and what types of teams. And so there's that, I guess, added issue too. Some places, patient navigators could hold the team together but may not be able to be billed for. Some places, nurse practitioners are required to do certain things and maybe not an RN without the NP degree. So it's important to know, understand your local context, but absolutely, the physician or midwife does not have to be the center of it. Next question for both of you, and this comes up in a lot of questions from the audience members, and that is what to do about glucose monitoring in general, CGM use, perhaps, but more broadly, how do you integrate glucose monitoring into these more collaborative group and team-based platforms for care delivery? Well, I can start with group care in the low-risk models. Patients having control of their own data is kind of a core tenant of that. And so in the old days when we had our logs, I would actually have patients go through and circle every abnormal value before they even got to me. So that was part of the expectation of people coming in, being prepared. And it's like the Weight Watchers principle, like everybody on their best behavior, everybody having positive peer pressure and wanting to come prepared. So that was part of it. So yes, we still do do monitoring. It can take a long time. So if the groups start to get a little bit too big, it can take too much time. So there have been times when I have taken all of the information at the beginning, let my co-facilitator, the diabetes educator, do the first few activities while I'm going and kind of organizing and getting everything together and then coming back. And another really nice model that I saw Sarah Mazzoni do when she was at Denver Health, she's moved on now, but she actually had stations. So she would kind of be the diabetes management station where people will come to her for that. There was a psychologist who was kind of the behavioral health check-in, how are you doing from a mood standpoint? And there was a midwife who was there for, how was the pregnancy going? And she would leave and kind of go titrate and do everything she needed to do while the psychologist and the midwife would run most of the group. So there are many models, and it also depends on what the acuity is. Are these patients with GDM who are really well-controlled and you can do it quickly, or is that a little bit more? But it is all done in the context of the group space and anything that I can't handle in the group space because they're too sick or there's other issues, then we either stay a little bit late afterwards, or I will see patients in between groups for individual visits to make sure that their needs are cared for. Yeah, I will add that the concept of having control over your own data is key to the principle I told you all about, about self-regulation, and that data are owned by the patient, not by the clinical team, and that teaching patients to understand how their data, how their behaviors are translated to changes in their data is an essential part of that self-regulatory feedback process in learning. Just to address the comments about CGMs, and I know there are some comments about whether continuous glucose monitors might be a way to reduce some of the burdens, logistical burdens and health literacy burdens of gestational diabetes. On the one hand, I think the answer is potentially yes, that CGMs may be the way of the future in order to reduce both the logistical burdens of finger sticks, some of the scheduling burdens of log in, the logistics of logging. On the other hand, it's important to remember some of the access challenges and payer challenges we have with CGMs, and perhaps even more importantly right now, to remember the limitations of the evidence. Right now, there are only very small trials of CGM use in people with GDM. There are obviously excellent data, I'm not even going to touch that, on the use of CGMs for patients with type one or also emergingly type two diabetes. Type one, I think it is the standard of care to use continuous glucose monitors in pregnancy, but GDM, I just want to be very careful about that. It is not yet the standard of care. There are proposed large studies out there, including, for example, with the NICHD funded Maternal Fetal Medicine Units Network that's contemplating one such trial, but they don't yet exist. So I would say that I think that it will make a big deal or be a big deal for social determinants of health barriers when we eventually know if CGMs should be used for this population. But until we know that CGMs have either equal or better outcomes, we probably should not yet be incorporating them as standard of care. Next question is for both of you. I think a lot of people after this lunchtime talk are feeling pretty energized. They really want to see how they can take these principles into their own prenatal care models. And a lot of people in the audience are saying, well, I practice in a more traditional care model, perhaps, you know, it's still in person, individualized. If I am going to pivot and, in my own small way, start to deliver more patient-centered care, where should I start at an individual and perhaps in a clinic level? Should it be with screening for social needs, screening for health literacy, trying to develop and collaborate more in a team-based model? Like, from your own experiences and based on the evidence, if you had tips for people in the audience who are trying to start down this pathway for their patients, where do you think would be a good place to start? So I'm gonna- I would say, go ahead, Emi. Well, I was gonna say, I'm a community-engaged researcher, so I always answer this question in the same way. And it's, in some ways, ask the patients. Like, the people that you are serving, what do they most need? And then, in terms of what patients need, what is within your power to provide? There's a paper in my head that I haven't written yet about group care that says there's kind of a recipe. There's five things that you need to be able to have a successful group care program. If you have all five of them, go for it. Have your best diabetes group prenatal care program. It's gonna be wonderful. If you have four, you might struggle a little bit, but go for it. If you have three, do not stop, or do not go past go. Like, it's gonna be a mess. You're gonna be frustrated. It's gonna be terrible. Just to save people, because I've looked at so many group care programs through our trials, and I can almost predict from the beginning which ones are gonna be wildly successful and which ones are gonna really struggle. So I would say that there is not a one-size-fits-all for that question. It's the context of your community, the people that you're serving, what they want, and then what's in your power to provide. I love that, and I think that the other advice I would give to people who feel the care models we're speaking about seem too hard, too much of a change, I would say it is okay to start small. So if your clinic is lacking, let's say resources for social needs, don't start screening for social needs until you have established for yourself your repository of resources. Maybe you start small and find out where your food pantries are, who to go to for challenges with transportation, childcare, housing instability. Maybe you start very, very small and just have a call your neighborhood food bank and ask how patients can come to you. And maybe you also start very, very small with the health literacy approach, too, and just do a whole clinic review of your handouts and make sure that they seem culturally tailored, patient-centered, low health literacy, visually pleasing, modern, et cetera. So it doesn't have to mean that you're totally reinventing the care model in order to get to kind of the programs that we're speaking about. I think these nuggets of change can actually go a very long ways, too. Next question from the group, and that is people want to know more about the group-based model. Is there a curriculum that exists? Is it more, essentially, did you use pre-existing lectures and presentations for this type of work, or do such resources, are they easily available for that purpose? Sure, so first of all, in terms of lectures or those types of things, when we do group, I try to stay completely away from the imagery of didactics or sitting in a class or listening to somebody do a boring talk. Groups are fun. So we use fun adult learning principles. It's not sitting down and listening to somebody lecture at you. Actually, if I am tired of talking by the end of a two-hour group, I've done a poor job because the wisdom, the knowledge, is coming from the group. So the group members should really be leading it. So we have a curriculum, an idea of what we're going to talk about that day, but if I'm planning to talk about breastfeeding and the patient wants to talk about postpartum baby blues because they're terrified of it because they had it their last pregnancy, that's where we're going. There are, the main curriculum for pregnancy is Centering Pregnancy. So it's the Centering Healthcare Institute. They do an amazing, wonderful training, and so that is a well-established curriculum for group prenatal care, but it's not specific to diabetes. And so I actually found, so Megan Schellinger, who was at Indiana University, is now in Greenville, South Carolina. Sarah Mazzoni, who's now at the University of Washington, they were kind of the pioneers. They were doing this before me, and they literally gave me all of their stuff and said, here, do what you want with it in combination with those patients that I showed you. So we have a diabetes group care curriculum that I am more than happy to share, and it's that revolving door curriculum. So they don't start and end together. So, you know, you go through the four sessions and it goes back to the first one. And if a patient happens to hear a session twice, great. They're the expert. So they actually can share, and we do slightly different activities. So it doesn't always even feel like the same group, even though we have the same core content. I, you know, I love the idea of patients hearing things twice and then becoming the mentor, the buddy, the experienced person. I, we don't have a group of GDM care in my institution, but what I love seeing is the spontaneous waiting room interactions when patients are like getting their GTTs or sitting around for a long time. And there is so much learning to be done by having the experienced patients with lesser experience or newer patients, even in a non-structured setting. Totally agree. Next question is for Dr. Yee with regard to social determinants and appropriate utilization of tech. You talk about mobile apps, perhaps being a little different than telemedicine and even EMR utilization and how social determinants may impact utilization of those resources and that perhaps mobile apps may be different. If you can elaborate further, given the interest in mobile apps and the prenatal space, as well as in the diabetes space. Yeah, I, you know, I will fully disclose that one of my earlier grants at R21 a number of years ago focused on creating a web-based app for people with gestational diabetes and type 2 diabetes during pregnancy. And it was an eye-opening and exciting experience, but ultimately, you know, I think the pace of modern app-based technology and the reason why I differentiate it from telemedicine or portals, the pace of technology to develop an evidence-based app where you are really only delivering an intervention that is fully grounded in evidence cannot keep up with the pace of industry. And so it is very challenging to create an evidence-based app and a lot of the apps that are out there are not evidence-based, are perhaps beautiful and perhaps easy to use, maybe even well-liked by participants, but we don't necessarily have a solid understanding that they improve health outcomes. That doesn't mean we shouldn't use them, but I think we should be appropriately aware of the limitations of technology to change health. And instead think about apps as maybe something that like augments the care that happens rather than like a must-have tool that we know will improve health outcomes. We should all be aware that sometimes technology is developed at a pace that is faster than the evidence we can develop to say that it is going to improve human health. Whereas on the other hand, portals, just to define them, are usually in your electronic medical record. They allow patients to communicate with their physicians. Sometimes they're app-based, but you could also use them on a web, on your computer. And they allow you to communicate directly with your healthcare team. So I differentiate portals from apps in that portals are part of your EMR and apps are like an accessory educational or other intervention that may or may not improve your health outcome. Next question is for both of you, but I think stems from some people in the audience had with regard to group care. And that is, you know, we're here, we are broadly talking about some of this work was done for, you know, prenatal care. And then we say diabetes and pregnancy. Is it, what about the severity of diabetes, like for group-based care models or even team-based care to think about, you know, what to do about the A2s who may have slightly different needs than the A1s, putting everybody in the same room. And perhaps that also has, you know, when you're thinking about type two diabetes with regard to glycemic control and comorbidities and complications, how do you accommodate that, the severity piece and risk stratification in this model? So I'm gonna answer this question anecdotally. And in the very first diabetes group that I did, and I'm excluding type one. So I'm talking about type two or GDM right now. In the very first group I did, there was a patient who had 22 problems on her problem list. And they weren't like, they were legitimate, true problems. And our diabetes nurse was like, Ebony, she really needs this. Please put her in the group. And I was like, no, Ms. Nelly, she got too much going on. Like, I cannot deal with this. And so we went back and forth and she's like, just trust me. So we put this patient in the group and this is the same patient who barely showed up, like would barely speak to me, so depressed, like could not get anything going in terms of her care. And in group, activated, engaged, like came into her own, did everything she needed to do. And I will say in my years of providing group care, I have learned to trust the process. So other than a psychiatric issue where the person is just like paranoid or it's gonna be really disruptive to the group or something like that, I let everybody in group. And then we will deal with their additional issues in individual visits in between. But I actually think that people who are the sickest have the most going on, feel like the joys of pregnancy have been stripped away from them because they're dealing with all of this medical stuff. Often are the people who benefit the best. And even I had a patient who was a little bit slow and would kind of perseverate on things and go round and round. And I was like, how is this ever gonna go in a group? The group members were more patient than me because as she'd be perseverating for 10 minutes, and I'm like, okay, let's move on. They'd be like, oh no, she wasn't done talking yet. And put me in my place and treat her with compassion and kindness. So I would say, I think anybody can be in a group as long as you give them the additional support that they need in the in-between. Yeah, just again, to link this to some of the concepts we talked about earlier, isolation of a medical condition during pregnancy can be really detrimental to health outcomes, either mental health outcomes or physical health outcomes. And when people feel like they are alone, sometimes they, because of their medical complexity, I think they can sometimes shut down. And so anything we can do to reduce that isolation can make a big difference. And as we finally wrap up in our last two minutes, I do have some closing remarks, but Dr. Carter's in need. Any last remarks you would both like to make before we conclude today's seminar? I would just say thank you for having me. And we are in a, I think, a challenging period in medicine and as we're caring for people. And don't be afraid to get out of your comfort zone. So I don't have a prescription for like this is the right thing, but if you have an idea and you feel like it could make a difference and patients are open to it, be comfortable and okay to stretch. And sometimes you fail, right? Like our program has not been a roaring success in every way, but we've learned some really cool lessons through it. So I'd say be willing to stretch and take a risk. Yeah, absolutely. I just echo that. Be creative. Thank you both so much. As we wrap up, we would like to provide you with some resources for your reference. These resources will be provided to you via email following the webinar. This concludes today's program. We would like to thank the presenters as well as Blue Cross Blue Shield of Minnesota for making this program a possibility. We would also like to extend a big thank you to all of you for your time and participation in today's learning. As a testament to that, you can just see the amount of encouragement and participation in the Q&A session and chat is just phenomenal. We look forward to connecting with all of you again soon. Thank you.

gestational diabetes

maternal-fetal medicine

group prenatal care

postpartum glucose testing

multidisciplinary approach

patient empowerment

health literacy

community health workers

evidence-based strategies

maternal health

patient-centered care